Article

Myofascial Triggerpoint Release (MTR) for Treating Chronic Shoulder Pain: A New Approach

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  • CIT Research Institute
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Abstract

Background: This study comprehensively evaluated a myofascial triggerpoint release (MTR) technique for shoulder pain. Methods: Twenty-three (from an initial sample of 25) patients experiencing shoulder pain received MTR, in four 10-min sessions over a period of 2 weeks, applied exclusively on the more painful shoulder, with assessments being recorded both before and after treatment (and for pain at 1 and 13 months). Measures of stiffness and elasticity were collected to monitor the process of therapy, while subjective measures of pain and objective measures of pressure pain thresholds tracked primary outcomes. Secondary outcomes focused on suffering, stress, and quality of life. Results: A statistically significant decrease in stiffness and increase in elasticity was observed post intervention for the treated side only, while pressure pain thresholds improved on the untreated side as well. Reports of pain significantly decreased after treatment, with gains being maintained at 1 and 13 months following treatment. Levels of suffering, stress, and quality of life revealed statistically significant improvement as well. Conclusions: MTR resulted in clinically significant improvements in the primary measures of pain, objective mechanical tissue properties, and secondary measures in patients with chronic shoulder pain.

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... • Objective [4,18] • Non-invasive [1,4,18] Real-time [1,3,64] Required technical expertise [18] Less expensive [1,4] Handheld [1,3,4] Easy to use [1,3,4,66] Structures assessed Deep [1,4] Superficial [1,4] Type of stiffness measured Passive [1,3]: resistance to elongation or shortening or, in physical terms, the change in tension per unit change in length [67] Dynamic [1,25,68]: resistance to a force that deforms muscle initial shape [3,25,68] Measurement mode Elastic [4]/shear [3] modulus, that uses ultrasound radiation forces [4] Damped oscillation method following a dynamic transformation of the muscle in response to a short-term external mechanical impulse [69] ...
... • Objective [4,18] • Non-invasive [1,4,18] Real-time [1,3,64] Required technical expertise [18] Less expensive [1,4] Handheld [1,3,4] Easy to use [1,3,4,66] Structures assessed Deep [1,4] Superficial [1,4] Type of stiffness measured Passive [1,3]: resistance to elongation or shortening or, in physical terms, the change in tension per unit change in length [67] Dynamic [1,25,68]: resistance to a force that deforms muscle initial shape [3,25,68] Measurement mode Elastic [4]/shear [3] modulus, that uses ultrasound radiation forces [4] Damped oscillation method following a dynamic transformation of the muscle in response to a short-term external mechanical impulse [69] ...
... Several muscles have been assessed with myotonometry [1,4,7,14,18,25,49,56], however to our knowledge, among the scapular muscles, only the trapezius muscle has been assessed [1,7,14,21,25,26,63,66,68,77,78]. ...
Article
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Several tools have been used to assess muscular stiffness. Myotonometry stands out as an accessible, handheld, and easy to use tool. The purpose of this review was to summarize the psychometric properties and methodological considerations of myotonometry and its applicability in assessing scapular muscles. Myotonometry seems to be a reliable method to assess several muscles stiffness, as trapezius. This method has been demonstrated fair to moderate correlation with passive stiffness measured by shear wave elastography for several muscles, as well as with level of muscle contraction, pinch and muscle strength, Action Research Arm Test score and muscle or subcutaneous thickness. Myotonometry can detect scapular muscles stiffness differences between pre- and post-intervention in painful conditions and, sometimes, between symptomatic and asymptomatic subjects.
... The effectiveness of an intervention can be measured by performance tasks such as muscle strength ability, speed of walking and joint range of motion (RoM). Elements that are sometimes subjectively assessed are pain and stiffness; key contributors to functional movement and independence (Giovannelli et al., 2007;Gordon et al., 2015). The following chapters will describe the biomechanical measurement forms that are used to define and analyse physiotherapy interventions in literature, with focus on objective muscle response and movement patterns. ...
... Schneider et al. (2014) and Rätsep and Asser (2011) reported a decrease in stiffness and tone and an increase in decrement and Viir et al. (2006) showed elasticity to have wide variation in their results (Rätsep & Asser, 2011;Viir et al., 2006). Whereas the study by Gordon et al. (2015) saw a decrease in stiffness and increase in elasticity due to a manual therapy intervention (Gordon et al., 2015). The reason for this is unclear and was suggested by Schneider et al. (2014) to be the result of the muscle relaxed state. ...
... Schneider et al. (2014) and Rätsep and Asser (2011) reported a decrease in stiffness and tone and an increase in decrement and Viir et al. (2006) showed elasticity to have wide variation in their results (Rätsep & Asser, 2011;Viir et al., 2006). Whereas the study by Gordon et al. (2015) saw a decrease in stiffness and increase in elasticity due to a manual therapy intervention (Gordon et al., 2015). The reason for this is unclear and was suggested by Schneider et al. (2014) to be the result of the muscle relaxed state. ...
Thesis
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Background: Multiple Sclerosis (MS) has many disabling symptoms due to weakened signal propagation in the central nervous system. Manual therapeutics are often seen to have a positive effect on these symptoms with limited information as to why. The purpose of this project was to investigate a spinal mobilisation intervention, objectively measuring the changes it may be causing to muscle quality and movement patterns as a contribution to research in MS therapeutics. Methods: A series of 3 studies were designed to investigate the effects of a spinal mobilisation intervention on muscle quality and movement patterns. Study 1 tested people with lower back pain (LBP) as a pilot population (n=40), testing for an immediate effect on muscle quality. Study 2 replicated this with MS patients (n=20) assessing muscle quality, balance, and pain. Study 3 tested the intervention in a longer-term 4 bout study (n=20), assessing muscle quality, balance, pain, and fatigue. Results: Significant muscle stiffness reductions were seen in the LBP population post the intervention (p = 0.01, η2partial = 0.15). Baseline stiffness was found as a significant contributor (p = 0.002, R2 = 0.22). These muscular results were not replicated with the MS population. However, significant improvements in self-reported pain as a result of the intervention were revealed (p = 0.008, η2partial = 0.33). Study 3 findings demonstrated significant improvements from baseline in balance and fatigue measures as a result of the intervention. High variability in the data are seen within the MS population.
... Muscle release (or myofascial trigger point release), defined as deep pressure to areas of local tenderness, has been used to treat chronic painful muscle spasms, decrease pain, and increase range of motion [15,16]. Researchers have demonstrated that this technique effectively improved mechanical muscle properties in individuals with chronic shoulder pain [15]. ...
... Muscle release (or myofascial trigger point release), defined as deep pressure to areas of local tenderness, has been used to treat chronic painful muscle spasms, decrease pain, and increase range of motion [15,16]. Researchers have demonstrated that this technique effectively improved mechanical muscle properties in individuals with chronic shoulder pain [15]. However, no study has assessed the effect of the muscle release technique on the muscle activation and kinematics in individuals with FS. ...
... The FS group received the electrical heating pad for 15 min at a temperature between 42 and 45 degrees Celsius, followed by one-session of manual muscle release (PM, UT, ISp, TM, and posterior deltoid) for about 30 min right after the initial examination. The target muscle of intervention was positioned in the lengthened position, while the physical therapist used the elbow and fingers to give sustained pressure directly on the most tender points at the muscle belly for 60 to 90 s until the physical therapist felt the target muscles start to release or the patient felt the pain decrease ( Fig. 1) [15,16]. The same licensed physical therapist (Liao PW), who has had more than two years practicing this technique performed all the treatments. ...
Article
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Background: Contractile tissue plays an important role in mobility deficits in frozen shoulder (FS). However, no study has assessed the effect of the muscle release technique on the muscle activation and kinematics in individuals with FS. The purposes of this study were to assess the differences in shoulder muscle activity and kinematics between the FS and asymptomatic groups; and to determine the immediate effects of muscle release intervention in the FS group. Methods: Twenty patients with FS and 20 asymptomatic controls were recruited. The outcome measures included muscle activity of the upper and lower trapezius (UT and LT), infraspinatus (ISp), pectoralis major (PM), and teres major (TM), shoulder kinematics (humeral elevation, scapular posterior tilt (PT) and upward rotation (UR), shoulder mobility, and pain. Participants in the FS group received one-session of heat and manual muscle release. Measurements were obtained at baseline, and immediately after intervention. Multivariate analysis of variance was used for data analysis. The level of significance was set at α=0.05. Results: Compared to the controls, the FS group revealed significantly decreased LT (difference =55.89%, P=0.001) and ISp muscle activity (difference =26.32%, P =0.043) during the scaption task, and increased PM activity (difference =6.31%, P =0.014) during the thumb to waist task. The FS group showed decreased humeral elevation, scapular PT, and UR (difference = 35.36°, 10.18°, 6.73° respectively, P <0.05). Muscle release intervention immediately decreased pain (VAS drop 1.7, P <0.001); improved muscle activity during scaption (UT: 12.68% increase, LT: 35.46% increase, P <0.05) and hand to neck (UT: 12.14% increase, LT: 34.04% increase, P <0.05) task; and increased peak humeral elevation and scapular PT during scaption (95.18°±15.83° to 98.24°±15.57°, P=0.034; 11.06°±3.94° to 14.36°±4.65°, P=0.002), and increased scapular PT during the hand to neck (9.47°±3.86° to 12.80°±8.33°, P=0.025) task. No statistical significance was found for other group comparisons or intervention effect. Conclusion: Patients with FS presented with altered shoulder muscle activity and kinematics, and one-session of heat and manual muscle release showed beneficial effects on shoulder muscle performance, kinematics, mobility, and pain. Trial registration: Retrospectively registered on Jan 18, 2016 (ACTRN 12616000031460 ).
... Stiffness is defined as the biomechanical property of muscles and other biological tissues that characterizes the resistance to a contraction or to an external force deforming its initial shape. 49,50 A reduction in stiffness might, therefore, provide a possible explanation for the increased EHR in the current experiment. This hypothesis is in line with previous findings of reduced muscle stiffness and improved mobility of the shoulder after four interventions of myofascial trigger point release in patients with shoulder pain. ...
... This hypothesis is in line with previous findings of reduced muscle stiffness and improved mobility of the shoulder after four interventions of myofascial trigger point release in patients with shoulder pain. 49 As in vitro studies have demonstrated, stiffness regulation depends on various mechanisms, such as an altered cell contraction, e.g., of myofibroblasts, or changed hydration with respectively changed fluid dynamics. 50,51 In the present study, an altered cell contraction or changed fluid dynamics as a response to the mechanical stimuli of the MFR treatment might provide an explanation for the observed effect. ...
Article
Turnout in classical dance refers to the external rotation of the lower extremities so that the longitudinal axes of the feet form an angle of up to 180°. To what extent a myofascial manipulation (myo-fascial release, MFR) could enhance this external rotation is as yet unknown. In this pilot study, 16 students of dance and 3 dance instructors were randomly assigned to an intervention group (IG; N = 10) and a group of controls (CG; N = 9). Isolated external hip rotation (EHR) and functional turnout (TO) were evaluated three times (pre-, post-, and follow-up measurement) using a plurimeter and Functional Footprints® rotation discs. In addition, subjectively perceived physical flexibility (PPF) was determined by means of a written survey. The interval between pre-and post-measurement and between post-and follow-up measurement was 4 weeks. Only the IG received four 20-minute MFR treatments of the lower limb at weekly intervals between pre-and post-measurement. In both the post-measurement (pre-versus post: p = 0.038, d = 0.77) and the follow-up measurement (pre-versus follow-up: p < 0.001, d = 1.66) the IG showed a significantly improved isolated EHR of the right hip and a significantly increased PPF (pre-versus post: p = 0.047, d = 0.73; pre-versus follow-up: p = 0.012, d = 1.00). The left EHR as well as the right and left TO were not affected by the intervention. It was demonstrated that four sessions of MFR of the lower limb can induce an improvement in the isolated external hip rotation (right hip). The beneficial effects of the treatment regarding an improvement of functional turnout could not be entirely verified in this pilot study. However, the significant increase in the participants' subjective flexibility supports the promising trend in the objective parameters and emphasizes the need to undertake further research.
... , 107) (tabla 1). Con resultado similar a nuestra investigación, se encontraron valores catalogados de moderados a grandes según Cohen (356) en escalas de dolor general de hombro en 4 de esos estudios(101,103,105,107). En los trabajos científicos sobre la eficacia a nivel musculoesquelético de la terapia manual sobre el diafragma, únicamente un estudio (170) calculó el tamaño del efecto, catalogándose como pequeño el efecto en la disminución del dolor en la algometría de C4 de forma bilateral, muy similar al que obtuvimos en esa misma variable en el grupo diafragma (tabla 2). ...
Thesis
Effects of diaphragm muscle treatment in shoulder pain and mobility in subjects with rotator cuff injuries. Introduction: The rotator cuff inflammatory or degenerative pathology is the main cause of shoulder pain. The shoulder and diaphragm muscle have a clear relation through innervation and the connection through myofascial tissue. In the case of nervous system, according to several studies the phrenic nerve has communicating branches to the brachial plexus with connections to shoulder key nerves including the suprascapular, lateral pectoral, musculocutaneous, and axillary nerves, besides, the vagal innervation that receives the diaphragm and their connections with the sympathetic system could make this muscle treatment a remarkable way of pain modulation in patients with rotator cuff pathology. To these should be added a possible common embryological origin in some type of vertebrates. Considering the connection through myofascial system, the improving of chest wall mobility via diaphragm manual therapy could achieve a better function of shoulder girdle muscles with insertion or origin at ribs and those that are influenced by the fascia such as the pectoralis major muscle, latissimus dorsi and subscapularis. Objectives: • Main objective: To compare the immediate effect of diaphragm physical therapy in the symptoms of patients with rotator cuff pathology regarding a manual treatment over shoulder muscles. • Specific objectives: 1. To evaluate the immediate effectiveness of each of the three groups in shoulder pain using a numerical pain rating scale (NPRS) and compare between them. 27 2. To evaluate the immediate effectiveness of each of the three groups in shoulder range of motion (ROM) using an inclinometer and compare between them. 3. To evaluate the immediate effectiveness of each of the three groups in pressure pain threshold (PPT) using an algometer and compare between them. Material and method: A prospective, randomized, controlled, single-blind (assessor) trial with a previous pilot study in which a final sample size of 45 subjects was determined to people diagnosed with rotator cuff injuries and with clinical diagnosis of myofascial pain syndrome at shoulder. The sample were divided into 3 groups of treatment (15 subjects per group): 1. A direct treatment over the shoulder by ischemic compression of myofascial trigger points (MTP) (control / rotator cuff group). 2. Diaphragm manual therapy techniques (diaphragm group). 3. Active diaphragm mobilization by hipopressive gymnastic (hipopressive group). The pain and range of shoulder motion were assessed before and after treatment in all the participants by inclinometry, NPRS of pain in shoulder movements and algometry. The data obtained were analyzed by an independent (blinded) statistician, who compared the effects of each one of the treatments using the Student’s t-test for paired samples or the Wilcoxon signed rank test, and calculated the post -intervention percentage of change in every variable. An analysis of variance (ANOVA) followed by the post-hoc test or a non-parametric Kruskal-Wallis test for non-parametric multiple-groups comparisons were performed to compare pre- to post-intervention outcomes between groups. Effect-size estimates of each intervention and between groups were calculated to allow interpretation of results in a more functional and meaningful way. Results: Both the control group and diaphragm group showed a statistically (p< 0.005) and clinically significant improvement, as well as a significant effect size (moderate to strong), on the NPRS in shoulder flexion and abduction movements. Regarding NPRS in shoulder external rotation, only the control group obtained a significant effect size. There was a significant increase in shoulder abduction and external rotation ROM (p< Efectos del tratamiento del músculo diafragma en el dolor y la movilidad del hombro en sujetos con patología del manguito rotador. 28 0.001) with a significant effect size in the control group. The PPT at the xiphoid process of the sternum showed a statistically (p< 0.001) and clinically significant improvement in the diaphragm group. The hipopressive gymnastic treatment was found to be no clinically effective in the shoulder pain and mobility, and showed a less efficacy than the other two groups. Conclusion: Both the shoulder non-direct treatment by a protocol of diaphragm manual therapy techniques and the rotator cuff MTP intervention showed been clinically effective in reducing pain (NPRS) immediately in shoulder flexion and abduction movements. The ROM assessment improvements obtained post- intervention by the diaphragm group have not been enough to consider them as clinically significant. The control group has obtained a significant effect size in shoulder abduction and external rotation ROM improvement. Both the control group and the diaphragm group treatments have been more effective in improving shoulder pain and mobility than the hipopressive group. The control group intervention has been the most effective in improving shoulder external rotation pain and mobility. The diaphragm group intervention was more effective in improving PPT at the xiphoid process than the other groups. Neither the effect size nor clinical significance proves the short-term benefit of the hipopressive gymnastic treatment in shoulder pain and mobility. Future studies are necessary to show the effectiveness of the diaphragm manual therapy applied in several sessions to determine its long-term effects in shoulder pain and mobility.
... Studies using MyotonPRO have shown that the value of muscle tone increases with aging 39 and pathologies, 40 and in studies with positive results obtained by treatment, it has been shown that muscle tone decreases. 41 According to our study results, moderate-intensity vibration exposure did not change the muscle tone of (Ahead of Print) Level of statistical significance P < .05. The P indicates P value obtained from the independent-samples t test that determines whether there is a statistically significant difference between the means in 2 unrelated groups for normally distribution data; P* indicates P value obtained from the Mann-Whitney U test that determines whether there is a statistically significant difference between the means in 2 unrelated groups for not normally distributed data and d indicates effect size, Cohen d effect size means that d = 0.2 be considered a "small" effect size, 0.5 represents a "medium" effect size, and 0.8 represents a "large" effect size. ...
Article
Context: The research on the change in properties of the lower leg muscles by different intensity sinusoidal vertical whole-body vibration (SV-WBV) exposures has not yet been investigated. Objective: The purpose of this study was to determine effect of a 20-minute different intensity SV-WBV application to the ankle plantar flexor and dorsiflexor muscles properties and hamstring flexibility. Design: Prospective preintervention-postintervention design. Setting: Physiotherapy department. Participants: A total of 50 recreationally active college-aged individuals with no history of a lower leg injury volunteered. Interventions: The SV-WBV was applied throughout the session with an amplitude of 2 to 4 mm and a frequency of 25 Hz in moderate-intensity vibration group and 40 Hz in a vigorous-intensity vibration group. Main outcome measures: The gastrocnemius and tibialis anterior muscle tone was assessed with MyotonPRO, and the strength evaluation was made on the same lower leg muscles using hand-held dynamometer. The sit and reach test was used for the lower leg flexibility evaluation. Results: The gastrocnemius muscle tone decreased on the right side (d = 0.643, P = .01) and increased on the left (d = 0.593, P = .04) when vigorous-intensity vibration was applied. Bilateral gastrocnemius muscle strength did not change in both groups (P > .05). Without differences between groups, bilateral tibialis anterior muscle strength increased in both groups (P < .01). Bilateral gastrocnemius and tibialis anterior muscle tone did not change in the moderate-intensity vibration group (P > .05). Flexibility increased in both groups (P < .01); however, there was no statistically significant difference between the groups (d = 0.169, P = .55). Conclusions: According to study results, if SV-WBV is to be used in hamstring flexibility or ankle dorsiflexor muscle strengthening, both vibration exposures should be preferred. Different vibration programs could be proposed to increase ankle plantar flexor muscle strength in the acute results. Vigorous-intensity vibration exposure is effective in altering ankle plantar flexor muscle tone, but it is important to be aware of the differences between the lower legs.
... It enables measurement not only of muscles 27 , but also tendons 28 . Thus, MyotonPRO may become a basic evaluation technique in muscle and tendon assessment as a portable and convenient diagnostic and monitoring device in medical practice [29][30][31] . Thus, it is important to examine the inter-equipment variability between SWUE and hand-held MyotonPRO for accurately quantifying the stiffness of the resting stiffness of gastrocnemius muscle belly and Achilles tendon. ...
Article
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The purposes of this study were to compare Young's modulus values determined by shear wave ultrasound elastography (SWUE) with stiffness index obtained using a hand-held MyotonPRO device on the resting stiffness of gastrocnemius muscle belly and Achilles tendon; and to examine the test-retest reliability of those stiffness measurement using hand-held MyotonPRO. Twenty healthy volunteers participated in the study. The measurement values of muscle and tendon was determined in dominant legs. Each marker point was assessed using MyotonPRO and SWUE, respectively. Intra-operator reliability of MyotonPRO was established in 10 of the subjects. The correlation coefficients between the values of muscle and tendon stiffness indices determined by MyotonPRO and SWUE were calculated. Significant correlations were found for muscle and tendon stiffness and Young's modulus ranged from 0.463 to 0.544 (all P < 0.05). The intra-operator reliability ranged from good to excellent (ICC(3,1) = 0.787~0.928). These results suggest that the resting stiffness of gastrocnemius muscle belly and Achilles tendon measured by MyotonPRO is related to the Young's modulus of those quantified by SWUE. The MyotonPRO shows good intra-operator repeatability. Therefore, the present study shows that MyotonPRO can be used to assess mechanical properties of gastrocnemius muscle belly and Achilles tendon with a resting condition.
Article
Background The best physiotherapeutic approach in shoulder pathology that generates prolonged immobilization is still uncertain. Kinesitherapy remains the most widely used option. Myofascial therapy is a therapeutic approach in which the aim is to release fascial tension and regain mobility although its efficacy in shoulder pathology has not been sufficiently studied. This Prospective, single-blind randomized controlled trial in a university hospital setting aimed to compare the efficacy of myofascial therapy and kinesitherapy in improving function in shoulder pathology with prolonged immobilization. Methods Patients were randomly assigned to a control group or to the intervention group.Both groups completed a therapeutic exercise program. Main Outcome Measures: The QuickDash questionnaire was the primary outcome, Pain Visual Analog Scale and the Range Of Motion of the shoulder were the secondary outcomes. The outcomes were evaluated at baseline (T0), at 4 (T2), 8 (T2), and 12 weeks (T3) Results 44 participants were included. In the analysis of evolution over time, a significant improvement in functionality and range of motion measurements was observed in both groups (p < 0.05), although at 12 weeks only Myofasical Group achieved a clinically and statistically significant reduction in pain. Comparative analysis at 12 weeks revealed no statistically significant differences between the two therapies in the variables explored. Conclusions Both, myofascial therapy and kinesitherapy can improve function, mobility, and pain in patients with painful shoulder associated with prolonged immobilization, with no significant differences between therapies, although in the medium term only myofascial therapy achieves a clinically and statistically significant improvement in pain. Trial registration Trial registration: ClinicalTrials.gov NCT04944446.
Article
[Purpose] The purpose of this study was to clarify the changes in muscle properties and muscle function of the rectus femoris caused by transverse friction massage (TFM) and to analyze the relationship between them. [Participants and Methods] Muscle properties (tone, stiffness, elasticity) and muscle functions (range of motion of passive knee flexion, knee extension peak torque, electro-mechanical delay, rate of force development) of the rectus femoris muscle were measured at baseline and post-intervention in 26 healthy adult males under TFM and Control conditions. [Results] In the TFM condition, stiffness significantly decreased and the range of motion significantly increased. There was a positive and moderate correlation between stiffness and range of motion. [Conclusion] The results suggest that TFM of the rectus femoris muscle had an effect on stiffness and increased the range of motion.
Chapter
Specialized manual skills are used extensively in both evaluating and treating the canine patient. Manual techniques are used in an assessment to identify soft tissue abnormalities, muscle length tightness, limitations in passive range of motion (PROM), and restrictions in arthrokinematic motion. When assessing soft tissues, we must be able to distinguish between normal and pathological tissue characteristics. Flexibility is assessed with particular sensitivity to multijoint muscles. PROM provides information regarding quality and quantity of joint ROM with the use of end-feels and goniometry. Joint play is used to assess arthrokinematic or accessory joint motion. Identification and interpretation of abnormal findings will direct the therapist in determining the most appropriate and most efficient treatment techniques. Manual treatment involves a variety of soft tissue techniques, specific stretching techniques, PROM with overpressure and joint mobilization, including glides and traction. Soft tissue treatment techniques are designed to address a specific tissue type and pathology. For example, techniques used to increase circulation are different than techniques used to reduce adhesions or eliminate trigger points. Decreased flexibility is treated with direct and nondirect stretching techniques designed to optimize patient tolerance and effectiveness. Treatment of limited PROM depends on information gathered from end-feel assessment. Motion limited by an elastic end-feel will require different treatment techniques than motion that is limited by a boggy end-feel. Finally, joint mobilization consists of glides and traction. Different grades and techniques of mobilization are used to treat pain versus hypomobility.
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Purpose: To use a novel, non-invasive hand held device (MyotonPRO) to quantify ratios of relative non-neural tone and mechanical properties of the rectus femoris (RF) and biceps femoris (BF) muscles, and to assess reliability of a novice user. Relevance: The device offers rapid, objective testing of mechanical parameters of muscle in clinical or sports settings. Participants: 21 healthy males (20-35 years) Methods: Relaxed muscle parameters of RF and BFwere obtained using the MyotonPRO. The device applies a brief mechanical impact, producing muscle oscillations from which tone (state of intrinsic tension, indicated by frequency [Hz]) and mechanical properties of elasticity (logarithmic decrement) and stiffness (N/m) are measured. Data were collected on two days, one week apart. Two series of 10 single measurements on each muscle were used to test within-day reliability. The mean of the two sets was used for between-day reliability. Analysis: The relative parameters between RF and BF were expressed as a ratio. Reliability was assessed using intra-class correlation coefficients (ICCs). Results: The mean (±SD) RF:BF ratios for resting muscle were: frequency 1:0.96 (±0.05), decrement 1:1.10 (±0.17) and stiffness 1:0.95 (±0.07). Reliability of all three parameters was excellent within-sessions (ICCs 3,2 >0.99) and good between-days (ICCs 3,1 0.72-0.87). Conclusions: The relative resting tone and mechanical properties of RF and BF has been characterised in young males, with ratios close to 1:1. Measures made by a novice user were reliable, indicating that the MyotonPRO has the potential for assessing changes in muscle properties objectively over time. Studies are needed in large healthy cohorts of different ages, activity levels and genders to produce reference data for assessing patients. Implications: The relative tone and mechanical properties of RF and BF could potentially be used as a rapid method for assessing risk of injury is sporting populations and presence of abnormality in musculoskeletal and neurological conditions, once normal values have been established in relevant groups.
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Objective. Test-retest reliability of the myotonometer was investigated in patients with subacute stroke. Methods. Twelve patients with substroke (3 to 9 months poststroke) were examined in standardized testing position twice, 60 minutes apart, with the Myoton-3 myometer to measure tone, elasticity, and stiffness of relaxed bilateral biceps and triceps brachii muscles. Intrarater reliability of muscle properties was determined using intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and the minimal detectable change (MDC). Results. Intrarater reliability of muscle properties of bilateral biceps and triceps brachii muscles were good (ICCs = 0.79-0.96) except for unaffected biceps tone (ICC = 0.72). The SEM and MDC of bilateral biceps and triceps brachii muscles indicated small measurement error (SEM% <10%, MDC% <25%). Conclusion. The Myoton-3 myometer is a reliable tool for quantifying muscle tone, elasticity, and stiffness of the biceps and triceps brachii in patients with subacute stroke.
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To assess the usefulness of a pressure algometer to measure pressure pain threshold (PPT) for diagnosis of myofascial pain syndrome (MPS) in the upper extremity and trunk muscles. A group of 221 desk workers complaining of upper body pain participated in this study. Five physiatrists made the diagnosis of MPS using physical examination and PPT measurements. PPT measurements were determined for several muscles in the back and upper extremities. Mean PPT data for gender, side, and dominant hand groups were analyzed. Sensitivity and specificity of Fischer's standard method were evaluated. PPT cut-off values for each muscle group were determined using an ROC curve. Cronbach's alpha for each muscle was very high. The PPT in men was higher than in females, and the PPT in the left side was higher than in the right side for all muscles tested (p<0.05). There was no significant difference in PPT for all muscles between dominant and non-dominant hand groups. Diagnosis of MPS based on Fischer's standard showed relatively high specificity and poor sensitivity. The digital pressure algometer showed high reliability. PPT might be a useful parameter for assessing a treatment's effect, but not for use in diagnosis or even as a screening method.
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Shoulder pain is reported to be highly prevalent and tends to be recurrent or persistent despite medical treatment. The pathophysiological mechanisms of shoulder pain are poorly understood. Furthermore, there is little evidence supporting the effectiveness of current treatment protocols. Although myofascial trigger points (MTrPs) are rarely mentioned in relation to shoulder pain, they may present an alternative underlying mechanism, which would provide new treatment targets through MTrP inactivation. While previous research has demonstrated that trained physiotherapists can reliably identify MTrPs in patients with shoulder pain, the percentage of patients who actually have MTrPs remains unclear. The aim of this observational study was to assess the prevalence of muscles with MTrPs and the association between MTrPs and the severity of pain and functioning in patients with chronic non-traumatic unilateral shoulder pain. An observational study was conducted. Subjects were recruited from patients participating in a controlled trial studying the effectiveness of physical therapy on patients with unilateral non-traumatic shoulder pain. Sociodemographic and patient-reported symptom scores, including the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, and Visual Analogue Scales for Pain were compared with other studies. To test for differences in age, gender distribution, and education level between the current study population and the populations from Dutch shoulder studies, the one sample T-test was used. One observer examined all subjects (n = 72) for the presence of MTrPs. Frequency distributions, means, medians, standard deviations, and 95% confidence intervals were calculated for descriptive purposes. The Spearman's rank-order correlation (ρ) was used to test for association between variables. MTrPs were identified in all subjects. The median number of muscles with MTrPs per subject was 6 (active MTrPs) and 4 (latent MTrPs). Active MTrPs were most prevalent in the infraspinatus (77%) and the upper trapezius muscles (58%), whereas latent MTrPs were most prevalent in the teres major (49%) and anterior deltoid muscles (38%). The number of muscles with active MTrPs was only moderately correlated with the DASH score. The prevalence of muscles containing active and latent MTrPs in a sample of patients with chronic non-traumatic shoulder pain was high.
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Shoulder pain is a common musculoskeletal problem that is often chronic or recurrent. Myofascial trigger points (MTrPs) cause shoulder pain and are prevalent in patients with shoulder pain. However, few studies have focused on MTrP therapy. The aim of this study was to assess the effectiveness of multimodal treatment of MTrPs in patients with chronic shoulder pain. A single-assessor, blinded, randomized, controlled trial was conducted. The intervention group received comprehensive treatment once weekly consisting of manual compression of the MTrPs, manual stretching of the muscles and intermittent cold application with stretching. Patients were instructed to perform muscle-stretching and relaxation exercises at home and received ergonomic recommendations and advice to assume and maintain good posture. The control group remained on the waiting list for 3 months. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score (primary outcome), Visual Analogue Scale for Pain (VAS-P), Global Perceived Effect (GPE) scale and the number of muscles with MTrPs were assessed at 6 and 12 weeks in the intervention group and compared with those of a control group. Compared with the control group, the intervention group showed significant improvement (P < 0.05) on the DASH after 12 weeks (mean difference, 7.7; 95% confidence interval (95% CI), 1.2 to 14.2), on the VAS-P1 for current pain (mean difference, 13.8; 95% CI, 2.6 to 25.0), on the VAS-P2 for pain in the past 7 days (mean difference, 10.2; 95% CI, 0.7 to 19.7) and VAS-P3 most severe pain in the past 7 days (mean difference, 13.8; 95% CI, 0.8 to 28.4). After 12 weeks, 55% of the patients in the intervention group reported improvement (from slightly improved to completely recovered) versus 14% in the control group. The mean number of muscles with active MTrPs decreased in the intervention group compared with the control group (mean difference, 2.7; 95% CI, 1.2 to 4.2). The results of this study show that 12-week comprehensive treatment of MTrPs in shoulder muscles reduces the number of muscles with active MTrPs and is effective in reducing symptoms and improving shoulder function in patients with chronic shoulder pain. ISRCTN: ISRCTN75722066.
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The aim of this clinical trial was to evaluate the effect of 15 myofascial therapy treatments using ischemic compression on shoulder trigger points in patients with chronic shoulder pain. Forty-one patients received 15 experimental treatments, which consisted of ischemic compressions on trigger points located in the supraspinatus muscle, the infraspinatus muscle, the deltoid muscle, and the biceps tendon. Eighteen patients received the control treatment involving 15 ischemic compression treatments of trigger points located in cervical and upper thoracic areas. Of the 18 patients forming the control group, 16 went on to receive 15 experimental treatments after having received their initial control treatments. Outcome measures included a validated 13-question questionnaire measuring shoulder pain and functional impairment. A second questionnaire was used to assess patients' perceived amelioration, using a scale from 0% to 100%. Outcome measure evaluation was completed for both groups at baseline after 15 treatments, 30 days after the last treatment, and finally for the experimental group only, 6 months later. A significant group x time interval interaction was observed after the first 15 treatments, indicating that the experimental group had a significant reduction in their Shoulder Pain and Disability Index (SPADI) score compared with the control group (62% vs 18% amelioration). Moreover, the patients perceived percentages of amelioration were higher in the experimental group after 15 treatments (75% vs 29%). Finally, the control group subjects significantly reduced their SPADI scores after crossover (55%). The results of this study suggest that myofascial therapy using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.
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Our aim was to describe the differences in the presence of trigger points (TrPs) in the shoulder muscles and to investigate the presence of mechanical hypersensitivity in patients with unilateral shoulder impingement and healthy controls. Twelve patients with strictly unilateral shoulder impingement and 10 matched controls were recruited. TrPs in the levator scapula, supraspinatus, infraspinatus, subscapularis, pectoralis major, and biceps brachii muscles were explored. TrPs were considered active if the local and referred pain reproduced the pain symptoms and the patient recognized the pain as a familiar pain. Pressure pain thresholds (PPT) were assessed over the levator scapulae, supraspinatus, infraspinatus, pectoralis major, biceps brachii, and tibialis anterior muscles. Both explorations were randomly done by an assessor blinded to the subjects’ condition. Patients with shoulder impingement have a greater number of active (mean ± SD: 2.5 ± 1; P < 0.001) and latent (mean ± SD: 2 ± 1; P = 0.003) TrPs when compared to controls (only latent TrPs, mean ± SD: 1 ± 1). Active TrPs in the supraspinatus (67%), infraspinatus (42%), and subscapularis (42%) muscles were the most prevalent in the patient group. Patients showed a significant lower PPT in all muscles when compared to controls (P < 0.001). Within the patient group a significant positive correlation between the number of TrPs and pain intensity (r s = 0.578; P = 0.045) was found. Active TrPs in some muscles were associated to greater pain intensity and lower PPTs when compared to those with latent TrPs in the same muscles (P < 0.05). Significant negative correlations between pain intensity and PPT levels were found. Patients with shoulder impingement showed widespread pressure hypersensitivity and active TrPs in the shoulder muscles, which reproduce their clinical pain symptoms. Our results suggest both peripheral and central sensitisation mechanisms in patients with shoulder impingement syndrome.
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Subacromial impingement syndrome (SIS) is a frequent cause of shoulder pain. The aim of this study was to investigate the diagnostic values of clinical diagnostic tests, in patients with SIS. 72 female, 48 male patients with shoulder pain were included in the study. Five had bilateral shoulder pain, so 125 painful shoulders were evaluated. Details were recorded about the patients' ages and sexes, as well as characteristics of pain and related problems. Detailed physical examination and routine laboratory tests were performed. Conventional radiography and subsequent magnetic resonance imaging of the shoulder region of all patients were performed. Patients were divided into two groups according to the results of subacromial injection test, a reference standard test for SIS. Test positive patients constituted SIS group and test negative patients the non-SIS group. Sensitivity, specificity, accuracy, positive and negative predictive values of some clinical diagnostic tests such as Neer, Hawkins, horizontal adduction, painful arc, drop arm, Yergason and Speed tests for SIS were determined by using 2 x 2 table. The most sensitive diagnostic tests were found to be Hawkins test (92.1%), Neer test (88.7%) and horizontal adduction test (82.0%). Tests with highest specificity were drop arm test (97.2%), Yergason test (86.1%) and painful arc test (80.5%) consecutively. The highly sensitive tests seem to have low specificity values and the highly specific ones to have low sensitivity values. Although this finding suggests that these diagnostic tests are insufficient for certain diagnosis, it is suggested they play an important part in clinical evaluation.
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Altered muscle activity in the scapular muscles is commonly believed to be a factor contributing to shoulder impingement syndrome. However, one important measure of the muscular coordination in the scapular muscles, the timing of the temporal recruitment pattern, is undetermined. To evaluate the timing of trapezius muscle activity in response to an unexpected arm movement in athletes with impingement and in normal control subjects. Prospective cohort study. Muscle latency times were measured in all three parts of the trapezius muscle and in the middle deltoid muscle of 39 "overhand athletes" with shoulder impingement and compared with that of 30 overhand athletes with no impingement during a sudden downward falling movement of the arm. There were significant differences in the relative muscle latency times between the impingement and the control group subjects. Those with impingement showed a delay in muscle activation of the middle and lower trapezius muscle. The results of this study indicate that overhand athletes with impingement symptoms show abnormal muscle recruitment timing in the trapezius muscle. The findings support the theory that impingement of the shoulder may be related to delayed onset of contraction in the middle and lower parts of the trapezius muscle.
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In this paper, we propose techniques of surface electromyographic (EMG) signal detection and processing for the assessment of muscle fiber conduction velocity (CV) during dynamic contractions involving fast movements. The main objectives of the study are: 1) to present multielectrode EMG detection systems specifically designed for dynamic conditions (in particular, for CV estimation); 2) to propose a novel multichannel CV estimation method for application to short EMG signal bursts; and 3) to validate on experimental signals different choices of the processing parameters. Linear adhesive arrays of electrodes are presented for multichannel surface EMG detection during movement. A new multichannel CV estimation algorithm is proposed. The algorithm provides maximum likelihood estimation of CV from a set of surface EMG signals with a window limiting the time interval in which the mean square error (mse) between aligned signals is minimized. The minimization of the windowed mse function is performed in the frequency domain, without limitation in time resolution and with an iterative computationally efficient procedure. The method proposed is applied to signals detected from the vastus laterialis and vastus medialis muscles during cycling at 60 cycles/min. Ten subjects were investigated during a 4-min cycling task. The method provided reliable assessment of muscle fatigue for these subjects during dynamic contractions.
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To review and summarize the methodological challenges in clinical trials of bodywork or handson mind-body therapies such as Feldenkrais Method, Alexander Technique, Trager Work, Eutony, Body Awareness Therapy, Breath Therapy, and Rolfing, and to discuss ways these challenges can be addressed. Review and commentary. Search of databases PubMed and EMBASE and screening of bibliographies. Published clinical studies were included if they used individual hands-on approaches and a focus on body awareness, and were not based on technical devices. Of the 53 studies identified, 20 fulfilled inclusion criteria. No studies blinded subject to the treatment being given, but 5 used an alternative treatment and blinded participants to differential investigator expectations of efficacy. No study used a credible placebo intervention. No studies reported measures of patient expectations. Patient expectations have been measured in studies of other modalities but not of hands-on mind-body therapies. Options are presented for minimizing investigator and therapist bias and bias from differential patient expectations, and for maintaining some control for nonspecific treatment effects. Practical issues with recruitment and attrition resulting from volunteer bias are addressed. Rigorous clinical trials of hands-on complementary and alternative therapy interventions are scarce, needed, and feasible. Difficulties with blinding, placebo, and recruitment can be systematically addressed by various methods that minimize the respective biases. The methods suggested here may enhance the rigor of further explanatory trials.
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Compromised shoulder movement due to pain, stiffness, or weakness can cause substantial disability and affect a person's ability to carry out daily activities (eating, dressing, personal hygiene) and work.w1 Self reported prevalence of shoulder pain is estimated to be between 16% and 26%; it is the third most common cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner with new shoulder pain annually.1 Occupations as diverse as construction work and hairdressing are associated with a higher risk of shoulder disorders. Physical factors such as lifting heavy loads, repetitive movements in awkward positions, and vibrations influence the level of symptoms and disability, and psychosocial factors are also important.w1 Recent studies suggest that chronicity and recurrence are common.2 3 Common shoulder disorders exhibit similar clinical features, and the lack of consensus on diagnostic criteria and concordance in clinical assessment complicates treatment choices.3 w2-w5 This review proposes an evidence based approach using a simplified classification of shoulder problems, incorporating diagnostic techniques applicable to a primary care consultation and a “red flag” system to identify potentially serious disease. We incorporated the latest consensus from systematic reviews and publications identified by a literature search through Medline, CINAHL, AMED, the Cochrane Library (Central, CDSR, HTA, DARE), Clinical Evidence, Best Evidence, Embase, British Nursing Index, PEDro,w6 Web of Science (social science and science citation indexes), and bmj.com. The search strategy included the terms “shoulder pain”, “rotator cuff disorder”, “rotator cuff tear”, “frozen shoulder”, and “primary care”. We found six published systematic reviews of interventions for shoulder disorders and one health technology assessment systematic review of diagnostic tests for the assessment of shoulder pain.4–10 A topic search within Clinical Evidence identified the section “Shoulder pain.”11 We identified and critically appraised other …
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The aim of the study was to characterize the electromechanical properties of skeletal muscle during isometric loading as well as to assess the potential of estimating intramuscular pressure by electrical and mechanical methods. Simultaneous electromyography (EMG), mechanical myotonometry (MYO, frequency and decrement of decay) and intramuscular pressure (IMP) measurements were conducted at rest and during short-term and long-term isometric contractions in patients with chronic pain in the anterior leg or dorsal forearm. The EMG amplitude and MYO(freq) accounted significantly (24-73%, p < 0.0001) for the variations in the IMP under short-term isometric loading. The IMP, EMG and MYO(freq) increased linearly with the relative muscle load (r = 0.868-0.993, p < 0.05). Mean values of EMG amplitudes at the contraction levels of 75% and 100% maximum voluntary contraction (MVC) and MYO(freq) values at all contraction levels (0-100% MVC) were higher for subjects with pathological values of IMP than for those with IMP values in the normal range. Total changes in IMP and EMG amplitude during 1 min isometric contraction were linearly interrelated (r = 0.747, p < 0.0001). We conclude that both surface electromyography and myotonometry parameters are indicative of intramuscular pressure, but neither of these methods can be used alone to diagnose non-invasively chronic compartment syndrome with acceptable accuracy.
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This research work is dedicated to occupational health problems caused by ergonomic risks. The research object was road building industry, where workers have to work very intensively, have long work hours, are working in forced/constrained work postures and overstrain during the work specific parts of their bodies. The aim of this study was to evaluate the work heaviness degree and to estimate the muscle fatigue of workers after one week work cycle. The study group consisted of 10 road construction and maintenance workers and 10 pavers aged between 20 and 60 years. Physical load were analyzed by measuring heart rate (HR), work postures (OWAS) and perceived exertion (RPE). Assessments of the muscles strain and functional state (tone) were carried out using myotonometric (MYO) measurements. The reliability of the statistical processing of heart rate monitoring and myotonometry data was determined using correlating analysis. This study showed that that road construction and repairing works should be considered as a hard work according to average metabolic energy consumption 8.1 +/- 1.5 kcal/min; paving, in its turn, was a moderately hard work according to 7.2 +/- 1.1 kcal/min. Several muscle tone levels were identified allowing subdivision of workers into three conditional categories basing on muscle tone and fatigue: I--absolute muscle relaxation and ability to relax; II--a state of equilibrium, when muscles are able to adapt to the work load and are partly able to relax; and III--muscle fatigue and increased tone. It was also found out that the increase of muscle tone and fatigue mainly depend on workers physical preparedness and length of service, and less on their age. We have concluded that a complex ergonomic analysis consisting of heart rate monitoring, assessment of compulsive working postures and myotonometry is appropriate to assess the work heaviness degree and can provide prognosis of occupational pathology or work-related musculoskeletal disorders for the workers under different workload conditions. These results can also be used when deciding on necessary rest time and its periodicity.
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The aim of the study was to examine the effect of experimental unilateral upper trapezius muscle pain on the relative activation of trapezius muscle subdivisions bilaterally during repetitive movement of the upper limb. Surface EMG signals were detected from nine healthy subjects from the upper, middle and lower divisions of trapezius during a repetitive bilateral shoulder flexion task. Measurements were performed before and after injection of 0.5 ml hypertonic (pain condition) and isotonic (control) saline into the upper division of the right trapezius muscle in two experimental sessions. On the painful side, upper trapezius showed decreased EMG amplitude (average rectified value, ARV) and lower trapezius increased ARV throughout the entire task following the injection of hypertonic saline (40.0 +/- 22.2 vs. 26.0 +/- 17.4 microV, and 12.5 +/- 7.6 vs. 25.6 +/- 14.8 microV, respectively, at the beginning of the contraction). On the side contralateral to pain, greater estimates of ARV were identified for the upper division of trapezius as the task progressed (37.4 +/- 20.2 vs. 52.7 +/- 28.4 microV, at the end of the contraction). Muscle fiber conduction velocity did not change with pain in all three divisions of the right trapezius muscle. The results suggest that local elicitation of nociceptive afferents in the upper division of the trapezius induces reorganization in the coordinated activity of the three subdivisions of the trapezius in repetitive dynamic tasks.
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Five male triathletes of the Estonian national junior team were observed during a seven-week competition period. The Myoton-2 equipment was used to describe the viscoelastic parameters of the skeletal muscles. The frequency of damped mechanical oscillation of the muscle tissue (Hz - indicating the tension in the muscle), logarithmic decrement of the oscillations (Theta - indicating the elasticity of the muscle) and stiffness (N m(-1)) of the muscle tissue were registered bilaterally in eight muscles in both the relaxed and the contracted states: BB - biceps brachii (caput longum); TB - triceps brachii (caput longum); BF - biceps femoris (caput longum); RF - rectus femoris; TA - tibialis anterior; GC - gastrocnemius (caput mediale); LD - latissimus dorsi; PM - pectoralis major (pars sternocostalis). A portable massage table was used for the subject to rest on during the measuring. For the measurement of the anterior muscles, the subject lay supine; for the posterior muscles the prone position was used. The (isometric) contraction was standardized simply by the same measuring position of the limb-the subject raised his arm or leg to an angle of 45 degrees from the horizontal level, using a 2.3 kg dumb-bell as an additional weight for the upper limb. The tarsal dorsiflexion and plantarflexion was performed against a fixed table to contract the crural muscles. The elasticity of the skeletal muscle is higher for the contracted state with respect to the relaxed one (p < 0.0001) and is described by decline of the value of logarithmic decrement, the stiffness and the tension in the muscle increases (p < 0.0001 for both parameters). The measured skeletal muscles differ significantly (p < 0.0018) by the viscoelastic properties in the relaxed state. In the relaxed state, TA was the most elastic (mean +/- SD; Theta-0.74 +/- 0.13), stiff (mean +/- SD; 346.68 +/- 60.34 N m(-1)) and tense muscle (mean +/- SD; 18.72 +/- 1.55 Hz). In the contracted state, the elasticity of TA did not change (0.76 +/- 0.14) while the stiffness and the tension in this muscle rose significantly (93% and 38%, accordingly). Personal differences (p < 0.005) exist if pooled data from the muscles are compared between the subjects.
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To investigate the course and prognosis of shoulder pain in the first 6 months after presentation to the general practitioner. We separately studied patients with acute, subacute and chronic shoulder pain, as duration of symptoms at presentation has been shown to be the strongest predictor of outcome. A prospective cohort study with 6 months follow-up was carried out in The Netherlands, including 587 patients with a new episode of shoulder pain. Patients were categorized as having acute (symptoms <6 weeks), subacute (6-12 weeks) or chronic (>3 months) shoulder pain. The course of shoulder pain, functional disability and quality of life was analysed over 6 months. Patient and disease characteristics, including physical and psychosocial factors, were investigated as possible predictors of outcome using multivariable regression analyses. Acute shoulder symptoms showed the most favourable course over 6 months follow-up, with larger pain reduction and improvement of functional disability. Patients with chronic shoulder symptoms showed the poorest results. The multivariable regression analysis showed that predictors of a better outcome at 6 months for acute shoulder pain were lower baseline disability scores and higher baseline pain intensity (explained variance 46%). Predictors of a better outcome for chronic shoulder pain were lower scores on pain catastrophizing and higher baseline pain intensity (explained variance 21%). The results indicate that, besides a different course of symptoms in patients presenting with acute or chronic shoulder pain, predictors of outcome may also differ with psychosocial factors being more important in chronic shoulder pain.
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The MyotonPRO (Myoton Ltd; London) is a new portable device for measuring muscle mechanical properties (e.g. tone) and its reliability has yet to be established. Little is known about between-limb symmetry of mechanical properties in healthy older people, despite symmetry often being used as a measure of unilateral abnormalities in clinical assessment. Since quadriceps is important for mobility, it was selected for the present study. To investigate: (i) between-day intra-rater reliability of a novice user of MyotonPRO; (ii) between-side symmetry of mechanical properties of quadriceps in older males. Twenty healthy, community dwelling, right-lower-limb-dominant males (mean age 71.7, range 65-82 years) were studied. With the participant in relaxed supine lying, the MyotonPRO applied two consecutive sets of 10 taps to induce muscle oscillations of rectus femoris, from which measurements of decrement (elasticity), frequency (tone), and stiffness were obtained. Tests were performed on two occasions at the same time and day of the week, one week apart. Repeated measurements had very high within-day (intraclass correlation coefficient, ICC 3,1>0.90) and high between-day (ICC 3,2>0.70; mean of two measurement sets) reliability. There was no statistically significant difference between muscle mechanical properties of the dominant and non-dominant muscles (<2.5% difference; p>0.05), thereby indicating symmetry. High intra-rater reliability was established for MyotonPRO measurements of quadriceps in healthy older males, which were symmetrical between sides. These findings indicate that larger studies are warranted to establish normal reference ranges of data with which to compare patients with muscle abnormalities.
Article
The aim of this case series was to investigate changes in pain and pressure pain sensitivity after manual treatment of active trigger points (TrPs) in the shoulder muscles in individuals with unilateral shoulder impingement. Twelve patients (7 men, 5 women, age: 25 ± 9 years) diagnosed with unilateral shoulder impingement attended 4 sessions for 2 weeks (2 sessions/week). They received TrP pressure release and neuromuscular interventions over each active TrP that was found. The outcome measures were pain during arm elevation (visual analogue scale, VAS) and pressure pain thresholds (PPT) over levator scapulae, supraspinatus infraspinatus, pectoralis major, and tibialis anterior muscles. Pain was captured pre-intervention and at a 1-month follow-up, whereas PPT were assessed pre- and post-treatment, and at a 1-month follow-up. Patients experienced a significant (P < 0.001) reduction in pain after treatment (mean ± SD: 1.3 ± 0.5) with a large effect size (d > 1). In addition, patients also experienced a significant increase in PPT immediate after the treatment (P < 0.05) and one month after discharge (P < 0.01), with effect sizes ranging from moderate (d = 0.4) to large (d > 1).A significant negative association (r(s) = -0.525; P = 0.049) between the increase in PPT over the supraspinatus muscle and the decrease in pain was found: the greater the decrease in pain, the greater the increase in PPT. This case series has shown that manual treatment of active muscle TrPs can help to reduce shoulder pain and pressure sensitivity in shoulder impingement. Current findings suggest that active TrPs in the shoulder musculature may contribute directly to shoulder complaint and sensitization in patients with shoulder impingement syndrome, although future randomized controlled trials are required.
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Latent Myofascial Trigger Points are pain-free neuromuscular lesions that have been found to affect muscle activation patterns in the unloaded state. The aim was to extend these observations to loaded motion by investigating muscle activation patterns in upward scapular rotator muscles (upper and lower trapezius and serratus anterior) hosting Latent Myofascial Trigger Points simultaneously with lesion-free synergists for shoulder abduction (infraspinatus and middle deltoid). This approach allowed examination of the effects of these lesions on both their hosts and their lesion-free synergists in order to understand their effects on the performance of shoulder abduction. Surface electromyography was employed to measure the timing of onset of muscle activation of the upper and lower trapezius and serratus anterior (upward scapular rotators), infraspinatus (rotator cuff) and middle deltoid (abductor of the arm) initially without load and then with light (1-4 kg) dumbbells. Comparisons were made between control (no Latent Trigger Points; n=14) and Latent Trigger Point (n=28) groups. The control group displayed a relatively stable sequence of muscle activation that was significantly different in timing and variability to that of the Latent Trigger Point group in all muscles except middle deltoid (all P<0.05). The Latent Trigger Point group muscle activation pattern under load was inconsistent, with the only common feature being the early activation of the infraspinatus. The presence of Latent Trigger Points in upward scapular rotators alters the muscle activation pattern during scapular plane elevation, potentially predisposing to overuse conditions including impingement syndrome, rotator cuff pathology and myofascial pain.
Article
The purpose of this study was to determine immediate effects of ischemic compression (IC) and ultrasound (US) for the treatment of myofascial trigger points (MTrPs) in the trapezius muscle. Sixty-six volunteers, all CEU-Cardenal Herrera University, Valencia, Spain, personnel, participated in this study. Subjects were healthy individuals, diagnosed with latent MTrPs in the trapezius muscle. Subjects were randomly placed into 3 groups: G1, which received IC treatment for MTrPs; G2, which received US; and G3 (control), which received sham US. The following data were recorded before and after each treatment: active range of motion (AROM) of cervical rachis measured with a cervical range of motion instrument, basal electrical activity (BEA) of muscle trapezius measured with surface electromyography, and pressure tolerance of MTrP measured with visual analogue scale assessing local pain evoked by the application of 2.5 kg/cm(2) of pressure using a pressure analog algometer. The results showed an immediate decrease in BEA of the trapezius muscle and a reduction of MTrP sensitivity after treatment with both therapeutic modalities. In the case of IC, an improvement of AROM of cervical rachis was also been obtained. In this group of participants, both treatments were shown to have an immediate effect on latent MTrPs. The results show a relation among AROM of cervical rachis, BEA of the trapezius muscle, and MTrP sensitivity of the trapezius muscle gaining short-term positive effects with use of IC.
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Prior studies suggest manual therapy (MT) as effective in the treatment of musculoskeletal pain; however, the mechanisms through which MT exerts its effects are not established. In this paper we present a comprehensive model to direct future studies in MT. This model provides visualization of potential individual mechanisms of MT that the current literature suggests as pertinent and provides a framework for the consideration of the potential interaction between these individual mechanisms. Specifically, this model suggests that a mechanical force from MT initiates a cascade of neurophysiological responses from the peripheral and central nervous system which are then responsible for the clinical outcomes. This model provides clear direction so that future studies may provide appropriate methodology to account for multiple potential pertinent mechanisms.
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Fourteen subjects were evaluated by needle electromyography in a trapezius myofascial trigger point and simultaneously in adjacent nontender trapezius muscle fibers during a control condition (forward counting), a stressful condition (mental arithmetic), and resting baselines. Based on recent data implicating autonomic innervation in muscle function, we hypothesized that the trigger point would be more responsive than the adjacent muscle to psychological stress. The results showed increased trigger point electromyographic activity during stress, whereas the adjacent muscle remained electrically silent. These results suggest a mechanism by which emotional factors influence muscle pain. This may have significant implications for the psychophysiology of pain associated with trigger points.
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Poorly controlled cancer pain is a significant public health problem throughout the world. There are many barriers that lead to undertreatment of cancer pain. One important barrier is inadequate measurement and assessment of pain. To address this problem, the Pain Research Group of the WHO Collaborating Centre for Symptom Evaluation in Cancer Care has developed the Brief Pain Inventory (BPI), a pain assessment tool for use with cancer patients. The BPI measures both the intensity of pain (sensory dimension) and interference of pain in the patient's life (reactive dimension). It also queries the patient about pain relief, pain quality, and patient perception of the cause of pain. This paper describes the development of the Brief Pain Inventory and the various applications to which the BPI is suited. The BPI is a powerful tool and, having demonstrated both reliability and validity across cultures and languages, is being adopted in many countries for clinical pain assessment, epidemiological studies, and in studies of the effectiveness of pain treatment.
Article
To investigate the effect of phentolamine, a sympathetic blocking agent, on the spontaneous electrical activity (SEA) recorded from a locus of a myofascial trigger spot (MTrS), equivalent to a human trigger point, in rabbit skeletal muscle. Randomized control trial. A university medical laboratory. Nine adult New Zealand rabbits. In the experimental group phentolamine mesylate (1mg/kg) was injected into the external iliac artery, followed by flushing with normal saline. The control group was treated with normal saline instead of phentolamine using the same procedure. SEA was recorded from multiple active loci of MTrSs in the biceps femoris muscle: initially SEA in the same locus was recorded before and immediately after phentolamine (or normal saline) injection; then SEA was recorded from 25 different active loci. The mean of the average integrated signal (AIS) of SEA was analyzed, comparing the effects of phentolamine and normal saline on SEA. In the same active locus, the AIS of SEA showed statistically a linear decay with time after phentolamine injection, with a correlation coefficient of .56 at p < .05. However, no statistical relationship could be derived for the control group data with time by using regression analysis, probably because of large variations among the rabbits and movement artifacts during the experiment. In 25 different loci in the phentolamine group, the mean of the AIS of SEA (7.92 microV) was significantly lower than that of the control group (9.89 microV) at p < .05. The results support the hypothesis that the autonomic nervous system is involved in the pathogenesis of myofascial trigger points. The application of the AIS as an evaluation index seems to be feasible in the quantitative measurement of SEA.
Article
To investigate the effectiveness of ultrasound treatment and trigger point injections in combination with neck-stretching exercises on myofascial trigger points of the upper trapezius muscle. Depression and anxiety associated with chronic pain were assessed using the Beck Depression Inventory (BDI) and the Taylor Manifest Anxiety Scale (TMAS). The study population comprised 102 patients who had myofascial trigger points in one side of the upper trapezius. The patients were randomly assigned to one of three groups: group 1 received ultrasound therapy to trigger points in conjunction with neck-stretching exercises; group 2 received trigger point injections and performed neck-stretching exercises; and group 3, the control group, performed neck-stretching exercises only. Treatment effectiveness was assessed using subjective pain intensity (PI) with a visual analog scale, pressure pain threshold (PT) with algometry, and range of motion (with a goniometer) of the upper trapezius muscle. Compared with the control group, patients in groups 1 and 2 had a statistically significant reduction in PI, an increase in PT, and an increase in range of motion. There were no statistically significant differences between treatment groups 1 and 2. Although not statistically significant, patients in the control group had better results at the 3-mo follow-up. The BDI scores indicated depression in 22.9% of the patient, with 4.8% of the patients having severe depression. High anxiety scores on the TMAS were present in 89.3% of the patients. When BDI and TMAS scores were compared with PI or PT levels, no significant correlations were found, but when compared with pain duration before treatment, correlations were significant. Patients with myofascial pain syndrome had higher scores for anxiety than for depression. When combined with neck stretching exercises, ultrasound treatment and trigger point injections were found to be equally effective.
Article
To review the efficacy of common interventions for shoulder pain. We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, Medline, Embase, Cinahl, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association. Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded. Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable. Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3. 0). The results of only three studies investigating rotator cuff tendonitis could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees, 95% CI 14 to 55) was the only positive finding. There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.
Article
To determine the value of elements of the bedside history and physical examination in predicting arthrography results in older patients with suspected rotator cuff tear (RCT). Retrospective chart review Orthopedic practice limited to disorders of the shoulder 448 consecutive patients with suspected RCT referred for arthrography over a 4-year period Presence of partial or complete RCT on arthrogram 301 patients (67.2%) had evidence of complete or partial RCT. Clinical findings in the univariate analysis most closely associated with rotator cuff tear included infra- and supraspinatus atrophy (P < .001), weakness with either elevation (P < .001) or external rotation (P < .001), arc of pain (P = .004), and impingement sign (P = .01). Stepwise logistic regression based on a derivation dataset (n = 191) showed that weakness with external rotation (Adjusted Odds Ratio (AOR) 6.96 (3.09, 13.03)), age > or = 65 (AOR 4.05(2.47, 16.07)), and night pain (AOR 2.61 (1.004, 7.39)) best predicted the presence of RCT. A five-point scoring system developed from this model was applied in the remaining patient sample (n = 216) to test validity. No significant differences in performance were noted using ROC curve comparison. Using likelihood ratios, a clinical score = 4 was superior in predicting RCT to the diagnostic prediction of an expert clinician. This score had specificity equivalent to magnetic resonance imaging or ultrasonography in diagnosis of RCT. The presence of three simple features in the history and physical examination of the shoulder can identify RCT efficiently. This approach offers a valuable strategy to diagnosis at the bedside without compromising sensitivity or specificity.
Article
We report the results of 238 consecutive patients who underwent in total 261 acromioplasties because of chronic rotator cuff impingement. The procedure was performed either in conventional open technique (80) or arthroscopically (181). Two years (1-10) after the operation 68% of the patients treated with the open technique had an excellent or good result compared 82% of the patients treated arthroscopically by an experienced arthroscopic surgeon. Compared to the open technique, the arthroscopic procedure had a statistically significant superior result concerning outcome, operating time and hospital stay. Arthroscopic procedures performed by less experienced surgeons had inferior results.
Article
To compare the prevalence of motor endplate potentials (noise and spikes) in active central myofascial trigger points, endplate zones, and taut bands of skeletal muscle to assess the specificity of endplate potentials to myofascial trigger points. This nonrandomized, unblinded needle examination of myofascial trigger points compares the prevalence of three forms of endplate potentials at one test site and two control sites in 11 muscles of 10 subjects. The endplate zone was independently determined electrically. Active central myofascial trigger points were identified by spot tenderness in a palpable taut band of muscle, a local twitch response to snapping palpation, and the subject's recognition of pain elicited by pressure on the tender spot. Endplate noise without spikes occurred in all 11 muscles at trigger-point sites, in four muscles at endplate zone sites outside of trigger points (P = 0.024), and did not occur in taut band sites outside of an endplate zone (P = 0.000034). Endplate noise was significantly more prevalent in myofascial trigger points than in sites that were outside of a trigger point but still within the endplate zone. Endplate noise seems to be characteristic of, but is not restricted to, the region of a myofascial trigger point.
Article
The aim of the study was to examine the test-retest reliability of the Myoton-2 myometer for measuring skeletal muscle viscoelastic stiffness. Ten healthy volunteers took part. On day 1, the viscoelastic stiffness of the rectus femoris, vastus lateralis, biceps femoris, and gastrocnemius muscle (lateral and medial heads) was measured at rest using the Myoton-2 myometer. On day 2, the tests were repeated, and the rectus femoris was also examined during the maintenance of submaximal contractions of the quadriceps, and at a different resting muscle length. The myometer showed good to excellent test-retest reliability for all muscles (ICCs 0.80-0.93), except for the vastus lateralis (ICC 0.40). Viscoelastic stiffness showed a linear increase with increasing quadriceps' force output, and was higher in stretched than in shortened resting muscle. The Myoton-2 myometer is a reliable device for measuring the viscoelastic stiffness of resting muscle. Furthermore, viscoelastic stiffness showed the expected changes in response to increases in force output and muscle length, suggesting that the measurements were also valid. The results of this pilot study show that the Myoton-2 myometer is a simple, precise instrument for measuring muscle viscoelastic stiffness. If the findings can be confirmed in larger studies, further research should be carried out to examine its potential applications in the field of musculoskeletal medicine.
Article
Subacromial impingement syndrome is the most common disorder of the shoulder, resulting in functional loss and disability in the patients that it affects. This musculoskeletal disorder affects the structures of the subacromial space, which are the tendons of the rotator cuff and the subacromial bursa. Subacromial impingement syndrome appears to result from a variety of factors. Evidence exists to support the presence of the anatomical factors of inflammation of the tendons and bursa, degeneration of the tendons, weak or dysfunctional rotator cuff musculature, weak or dysfunctional scapular musculature, posterior glenohumeral capsule tightness, postural dysfunctions of the spinal column and scapula and bony or soft tissue abnormalities of the borders of the subacromial outlet. These entities may lead to or cause dysfunctional glenohumeral and scapulothoracic movement patterns. These various mechanisms, singularly or in combination may cause subacromial impingement syndrome.
Article
This article explores how myofascial trigger points (MTrPs) may relate to musculoskeletal dysfunction (MSD) in the workplace and what might be done about it. The cause of much MSD and pain is often enigmatic to modern medicine and very costly, just as the cause of MTrPs has been elusive for the past century, despite an extensive literature that is confusing because of restricted regional approaches and a seemingly endless variety of names. MTrPs are activated by acute or persistent muscle overload, which is characteristic of MSD in the workplace. MTrPs can involve any, and sometimes many, of the skeletal muscles in the body and are a major, complex cause of musculoskeletal pain. The clinical and etiological characteristics of MTrPs have been underexplored by investigators, leading to undertraining of health care professionals, underappreciation of their clinical importance. MTrPs have no gold standard diagnostic criterion, and no routinely available laboratory or imaging test. MTrPs require a specific non-routine examination and muscle-specific treatment for prompt relief when acute, and also resolution of perpetuating factors when chronic. After identifying a critical false assumption, electrodiagnostic studies are now making encouraging progress toward clarifying the etiology of MTrPs based on the 5- or 6-step positive-feedback model of the integrated hypothesis. Specific research needs are noted. MTrPs are treatable and they deserve increased attention and consideration by research investigators and clinicians.
Article
The shoulder joint has an important influence on arm- and hand function. Therefore, activities of daily living, working and leisure time can be negatively influenced by diseases of the shoulder joint. Problems of the shoulder joint can be induced by muscular dysbalance and poor body posture. There is a strong relationship between shoulder function and body posture. Conservative treatment and rehabilitation of the shoulder joint aims at improving the local dysfunction of the shoulder joint as well as at improving function and social participation. Antiinflammatory and pain medication, exercise, occupational, electro-, ultrasound and shock wave therapy, massage, thermotherapy and pulsed electromagnetic fields are used as conservative treatments. Exercise therapy aims at improving muscular performance, joint mobility and body posture. Occupational therapy aims at improving functional movements for daily living and work. Electrotherapy is primarily used to relieve pain. Shock wave and ultrasound therapy proved to be an effective treatment for patients with calcific tendinitis. The subacromial impingement syndrome can be effectively treated by conservative therapy.
Article
Prior systematic reviews of rehabilitation for nondescript shoulder pain have not yielded clinically applicable results for those patients with subacromial impingement syndrome (SAIS). The purpose of this study was to examine the evidence for rehabilitation interventions for SAIS. The authors used data source as the method. The computerized bibliographic databases of Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Database of Systematic Reviews were searched from 1966 up to and including October 2003. Key words used were "shoulder," "shoulder impingement syndrome," "bursitis," and "rotator cuff" combined with "rehabilitation," "physical therapy," "electrotherapy," "ultrasound," "acupuncture," and "exercise," limited to clinical trials. Randomized clinical trials that investigated physical interventions used in the rehabilitation of patients with SAIS with clinically relevant outcome measures of pain and quality of life were selected. The search resulted in 635 potential studies, 12 meeting inclusion criteria. Two independent reviewers graded all 12 trials with a quality checklist averaged for a final quality score. The mean quality score for 12 trials was 37.6 out of a possible 69 points. Various treatments were evaluated: exercise in six trials, joint mobilizations in two trials, laser in three trials, ultrasound in two trials, and acupuncture in two trials. The limited evidence currently available suggests that exercise and joint mobilizations are efficacious for patients with SAIS. Laser therapy appears to be of benefit only when used in isolation, not in combination with therapeutic exercise. Ultrasound is of no benefit, and acupuncture trials present equivocal evidence. The low to mediocre methodologic quality, small sample sizes, and general lack of long-term follow-up limit these findings for the development of useful clinical practice guidelines. Further trials are needed to investigate these rehabilitation interventions, the superiority of one intervention over another, and the long-term outcomes of rehabilitation. Moreover, it is imperative that clinical guidelines are developed to indicate those patients who are likely to respond to rehabilitation.
Article
This aim of this study was to characterize upper and lower trapezius muscle activity for patients experiencing frozen shoulder syndrome (FSS) compared to asymptomatic subjects. Fifteen patients suffering from unilateral FSS and 15 asymptomatic subjects voluntarily participated in this study. Data were gathered on electromyographic (EMG) activity obtained from the upper and lower trapezius muscles during maximal static arm elevations at six different testing positions: 60 and 120 degrees of flexion, abduction in the frontal plane, and abduction in the scapular plane. The group with FSS revealed increased upper trapezius EMG activity at the 60 degrees (mean difference = 12%, p < 0.003) and 120 degrees (mean difference = 24%, p < 0.004) testing positions, and increased lower trapezius EMG activity at the 120 degrees testing positions (mean difference = 6%, p < 0.002), compared to asymptomatic subjects. Higher ratios of the upper trapezius to lower trapezius EMG activity were also found in the patient group (p < 0.0005) compared to asymptomatic subjects. The results of this study indicate that the increased trapezius muscle activity may contribute to scapular substitution movement in compensation for impaired glenohumeral motion in patients with FSS. The insufficiency of the increased lower trapezius muscle activity should be an important consideration in the rehabilitation of patients experiencing FSS.
Article
Myofascial pain associated with myofascial trigger points (MTrPs) is a common cause of nonarticular musculoskeletal pain. Although the presence of MTrPs can be determined by soft tissue palpation, little is known about the mechanisms and biochemical milieu associated with persistent muscle pain. A microanalytical system was developed to measure the in vivo biochemical milieu of muscle in near real time at the subnanogram level of concentration. The system includes a microdialysis needle capable of continuously collecting extremely small samples (∼0.5 μl) of physiological saline after exposure to the internal tissue milieu across a 105-μm-thick semi-permeable membrane. This membrane is positioned 200 μm from the tip of the needle and permits solutes of <75 kDa to diffuse across it. Three subjects were selected from each of three groups (total 9 subjects): normal (no neck pain, no MTrP); latent (no neck pain, MTrP present); active (neck pain, MTrP present). The microdialysis needle was inserted in a standardized location in the upper trapezius muscle. Due to the extremely small sample size collected by the microdialysis system, an established microanalytical laboratory, employing immunoaffinity capillary electrophoresis and capillary electrochromatography, performed analysis of selected analytes. Concentrations of protons, bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-α, interleukin-1β, serotonin, and norepinephrine were found to be significantly higher in the active group than either of the other two groups (P < 0.01). pH was significantly lower in the active group than the other two groups (P < 0.03). In conclusion, the described microanalytical technique enables continuous sampling of extremely small quantities of substances directly from soft tissue, with minimal system perturbation and without harmful effects on subjects. The measured levels of analytes can be used to distinguish clinically distinct groups.
Article
The goal of this systematic review is to evaluate the effectiveness of different treatments for impingement syndrome and rotator cuff tear on the improvement in functional limitations and concomitant duration of sick leave. A systematic search for clinical trials or controlled studies was conducted with the following text words: should*, rotator cuff, impingement, work, sick leave, disabilit*, function*. Nineteen articles were included in this review. For functional limitations, there is strong evidence that extracorporeal shock-wave therapy is not effective, moderate evidence that exercise combined with manual therapy is more effective than exercise alone, that ultrasound is not effective, and that open and arthroscopic acromioplasty are equally effective on the long term. For all other interventions there is only limited evidence. We found many studies using range of motion and pain as outcome measures but functional limitations were less often used as an outcome measure in this type of research. Duration of sick leave was seldom included as an outcome measure.
Article
Myofascial pain syndrome (MPS) is caused by myofascial trigger points (MTrPs) located within taut bands of skeletal muscle fibers. Treating the underlying etiologic lesion responsible for MTrP activation is the most important strategy in MPS therapy. If the underlying pathology is not given the appropriate treatment, the MTrP cannot be completely and permanently inactivated. Treatment of active MTrPs may be necessary in situations in which active MTrPs persist even after the underlying etiologic lesion has been treated appropriately. When treating the active MTrPs or their underlying pathology, conservative treatment should be given before aggressive therapy. Effective MTrP therapies include manual therapies, physical therapy modalities, dry needling, or MTrP injection. It is also important to eliminate any perpetuating factors and provide adequate education and home programs to patients so that recurrent or chronic pain can be avoided.
Article
Shoulder pain is a common problem and although there are many accepted standard forms of conservative therapy for shoulder disorders including non-steroidal anti-inflammatory drugs, glucocorticosteroid injections, oral glucocorticosteroid medication, manipulation under anaesthesia, physical therapy, hydrodilatation (distension arthrography) and surgery, evidence of their efficacy is not well established. To review the efficacy of common interventions for shoulder pain. We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association. Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded. Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable. Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3.0). The results of only three studies investigating "rotator cuff tendonitis" could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees , 95% CI 14 to 55) was the only positive finding. There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.
Article
Incidence densities in primary care are often based on disease or region-specific code registration (e.g. 'epicondylitis', 'shoulder symptom') according to the International Classification of Primary Care (ICPC). Few estimates are available on arm, neck and shoulder complaints. Unknown, is the proportion missed due to registration with a non-region-specific code (e.g. 'muscle pain'). Therefore, we estimated the incidence in non-traumatic arm, neck and shoulder complaints in the age-group 18-64 years, and determined the contribution of non-specific codes to the total figure. In this prospective registration study, 21 general practitioners (GPs) from 13 Dutch general practices classified and registered patient's symptoms and diagnoses according to ICPC at each consultation during 12 consecutive months. Incidence densities were calculated. The incidence density was 97.4/1000 person-years (95% CI: 91.2-103.7). This results in 147 (95% CI: 138-157) incident cases/year for an average-sized GP-practice (2350 patients). Main contributors were: shoulder (L92, L08) and neck complaints (L01, L83). Of all incident consultations, 23% were registered with non-region-specific codes, mainly 'other musculoskeletal disease' (L99). Non-traumatic complaints of arm, neck and shoulder are frequently consulted for in Dutch primary care. When estimating morbidity in primary care, based on diagnostic codes, one should be aware of possible underestimation of morbidity and corresponding workload, when excluding codes not specific for that region or disease.
Article
To determine the reproducibility of manual palpation in identifying trigger points based on a systematic review of available literature. Medline (1965-2007), CINHAL (1982-2007), ISI Web of Science (1945-2007), and MANTIS (1966-2007) databases and reference lists of articles. Reproducibility studies relating to identification and diagnosis of trigger points through palpation. Acceptable studies were required to specifically consider either inter- or intrarater reliability of trigger point identification through manual palpation and include kappa statistics as part of their statistical assessment. Three independent reviewers considered the studies for inclusion and rated their methodologic quality based on the Standards for Reporting of Diagnostic Accuracy guidelines for the reporting of diagnostic studies. Eleven studies were initially included; however, 5 were subsequently excluded based on the inclusion and exclusion criteria. Only 2 studies were judged to be of high quality, and the level of evidence criteria suggested that, at best, moderate evidence could be found from which to make pronouncements on the literature. Only local tenderness of the trapezius (kappa range, .15-.62) and pain referral of the gluteus medius (kappa range, .298-.487) and quadratus lumborum (kappa range, .36-.501) were found to be reproducible. The methodologic quality of the majority of studies for the purpose of establishing trigger point reproducibility is generally poor. More high-quality studies are needed to comment on this procedure. Clinicians and scientists are urged to move toward simpler, global assessments of patient status.
Article
Diagnostic labels for shoulder pain (e.g., frozen shoulder, impingement syndrome) are widely used in international research and clinical practice. However, about 10 years ago it was shown that the criteria to define those labels were not uniform. Since an ongoing lack of uniformity seriously hampers communication and does not serve patients, we decided to evaluate the uniformity in definitions. Therefore, we compared the selection criteria of different randomised controlled trials (RCTs). This comparison revealed some corresponding criteria, but no uniform definition could be derived for any of the diagnostic labels. Besides the lack of uniformity, the currently used labels have only a fair to moderate interobserver reproducibility and in systematic reviews none of the separate trials using a diagnostic label show a large benefit of treatment. This, altogether, seems sufficient reason to reconsider their use. Therefore, we strongly suggest to abolish the use of these labels and direct future research towards undivided populations with "general" shoulder pain. Possible subgroups with a better prognosis and/or treatment result, based on common characteristics that are easily and validly reproducible, can then be identified within these populations.
Eine neue integrative Kombinationstherapie.
  • Gordon C.
  • Schleip R.
  • Gevirtz R.N.
  • Andrasik F.
Gordon, C., Schleip, R., Gevirtz, R.N., Andrasik, F., 2011. Eine neue integrative Kombinationstherapie. PT-Zeitschrift für Physiother. 63, 72e77.