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CHRONIC SHOULDER PAIN OF MYOFASCIAL ORIGIN:
AR
ANDOMIZED CLINICAL TRIAL USING ISCHEMIC
COMPRESSION THERAPY
Guy Hains, DC,
a
Martin Descarreaux, DC, PhD,
b
and François Hains, DC, MSc
a
ABSTRACT
Objective: 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.
Methods: 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.
Results: A significant group × 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%).
Conclusion: 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. (J Manipulative Physiol Ther
2010;33:362-369)
Key Indexing Terms: Shoulder Pain; Myofascial Pain Syndromes; Musculoskeletal Manipulations; Chiropractic
Shoulder pain is a common musculoskeletal com-
plaint; nearly half the population has at least one
episode of shoulder pain per year.
1
The prevalence
among 9696 adults of working age was 14.4%.
2
Upper
extremity pain and injury account for (8.6%) of the chief
complaints among chiropractic patients.
3
Painful or stiff
shoulder may be caused by neurologic or vascular disorders,
neoplasms, myofascial trigger points, referred pain from
internal organs, and disorders of the cervical spine.
4-6
Both the etiology and pathogenesis of shoulder disorders
tend to remain enigmatic. The complex anatomical and
functional structure of the shoulder joint often complicates
diagnosis and clinical management of shoulder lesion. This
has resulted in much confusion and a lack of consensus
regarding the classification and diagnostic criteria of
shoulder disorders.
1,4,7,8
Different pathologic conditions
often coexist at the shoulder, either as a consequence of
shared causes or because the presence of one disorder
predisposes to the occurrence of another.
2
The partial or complete tearing of the rotator cuff is often
asymptomatic.
9
Ninety-six asymptomatic patients were
examined using magnetic resonance imagery; 15% had
complete tearing of the rotator cuff and 20% had partial
tearing. The frequency of rotator cuff tearing seems to
increase with age. Of the 46 patients older than 60 years
who were examined, 28% had a complete tear of the rotator
cuff and 26% had partial tears. On the basis of these results,
the authors concluded that tears of the rotator cuff are often
compatible with normal painless functional activity and
occur with more frequency in older individuals.
9
In a
a
Private Practice, Trois-Rivières, Québec, Canada.
b
Professor, Université du Québec à Trois-Rivières, Québec,
Canada.
Submit requests for reprints to: Guy Hains, DC, 2930 Côte
Richelieu, Trois-Rivières, Québec, Canada G8Z 3Y8
(e-mail: guy.hains@cgocable.ca).
Paper submitted May 16, 2007; in revised form November 27,
2009; accepted February 11, 2010.
0161-4754/$36.00
Copyright © 2010 by National University of Health Sciences.
doi:10.1016/j.jmpt.2010.05.003
362
comprehensive study of an asymptomatic population,
ultrasound examination revealed the presence of ruptures
in more than 50% of the dominant shoulders among a
population in their seventies.
10
Although it is mostly
asymptomatic,
11
calcific tendonitis is often considered as a
possible cause of shoulder pain.
12,13
However, in a study of
925 symptomatic patients, 63 (6.8%) patients had some
evidence of calcification. In another group of 200
asymptomatic patients, 7.5% had calcified deposits in the
shoulder. The investigators concluded that the frequency of
shoulder calcification is virtually the same in both
symptomatic and asymptomatic patients.
12
In another trial,
it was said that the relationship between the calcium deposit
and the shoulder pain was unclear.
14
For most patients experiencing shoulder pain, a detailed
case history and clinical examination enable the clinician to
make appropriate clinical decisions regarding management
and prognosis.
4
Imaging such as radiography, arthrogra-
phy, computed tomographic scanning, and magnetic
resonance imaging should be reserved for difficult cases
where the diagnosis is insufficiently clear and conservative
measures have not been successful.
15,16
For instance,
radiographic evidence for degenerative arthritis can be
found in 24% patients with shoulder pain, but it cannot be
considered an adequate predictive value.
17
Common treatments for shoulder pain include phys-
iotherapy, antiinflammatory drugs, cryotherapy, local
anesthetic or steroid infiltrations, needling, and radiation
therapy.
18
In a cohort study of 127 patients reporting
shoulder disability, injection was a common treatment
(58%), whereas capsulitis was the most common
diagnosis (39%). In the same study, roughly one quarter
(22%) of patients reported a previous episode of shoulder
pain.
19
In a group of 349 patients with shoulder pain,
treated by 11 general practitioners, surgery was per-
formed on 4 patients only, in the following year.
20
For
these authors, an initial wait-and-see policy may prove to
be the preferred treatment strategy.
Ultrasound therapy is associated with short-term clinical
improvement. In a study where 32 shoulders were treated
using ultrasound and 29 receiving a sham treatment, after 6
weeks of treatments, patients who received ultrasound
treatment had a greater decrease in pain and a better quality
of life than those who had received sham treatment.
However, at 9 months, the differences between the groups
were no longer significant. The conclusion of the authors
was that ultrasound therapy is associated with short-term
clinical improvement for shoulder pain.
13
The natural history of shoulder pain is frequently
considered self-limiting. However, a 3-year follow-up
report found that 54% of patients had persistent pain,
whereas 90% of them had chronic disability.
21
In another
trial, 101 patients with shoulder pain were assessed, using a
pain questionnaire and a physical examination. Fifty-one
percent of them still experienced pain after 26 weeks and
41% after 12 to 18 months. The authors concluded that
patients seen for shoulder complaints in general practice
experience recurrence.
22
In another study of 92 subjects, 50
reported shoulder pain at a follow-up 3 years later.
21
A systematic review of 31 clinical trials was conducted
to evaluate the effectiveness of various therapeutic inter-
ventions for shoulder pain. The different clinical interven-
tions included antiinflammatory medications, intraarticular
cortisone injections, physiotherapy, manipulation under
anesthesia, hydrodilation, and surgery. Of all these inter-
ventions, only subacromial cortisone injections were found
to be more effective than placebos to increase abduction.
The investigators concluded that there is little scientific
evidence to support the effectiveness of the most commonly
used therapies for shoulder pain.
7
There are no reports in
the literature describing the efficacy of various treatment
interventions in cases of calcific tendonitis based on
controlled clinical trials,
23
and there are no randomized
clinical trials of surgical interventions.
7
The treatment of shoulder pain by using ischemic
compression on trigger points located in structures
surrounding the shoulder is based on the scientific rationale
that shoulder trigger points may be located in muscles,
ligaments, tendons, and articular capsules.
24
Patients with
trigger points in the supraspinatus muscle complain of a
deep aching pain in the middeltoid region.
5
Causes of these
shoulder trigger points include traumatisms and overuse
mechanisms.
25
A study has shown that myofascial therapy
(friction massage) seems to relieve pain in patients
experiencing chronic shoulder bursitis.
26
Its author sug-
gested that eliminating the trigger points located around the
shoulder area might be helpful for patients with shoulder
pain. The present authors hypothesize that eliminating the
trigger points in the shoulder area would normalize the
function and eliminate the pain.
The aim of this study was to evaluate the effect of 15
myofascial therapy treatments using ischemic compression
on trigger points located in the shoulder area in patients
with from chronic shoulder pain.
METHOD
This prospective randomized clinical trial was conducted
in a private clinic located in Trois-Rivières, Québec,
Canada. The study was approved by the ethics committee
of the Université du Québec à Trois-Rivières. All subjects
were recruited through local advertising. To take part in the
trial, participants had to be aged between 30 and 60 and to
have experienced shoulder pain on a daily basis for at least
the previous 3 months. Shoulder pain was defined as pain in
the shoulder and upper arm, at rest or caused or aggravated
by movement.
27
Participants also had to be able to raise the
arm vertically above the head. The intensity of the pain had
to be at least 5, on a 10-cm visual analog pain scale. All
363
Hains, Descarreaux and HainsJournal of Manipulative and Physiological Therapeutics
Ischemic Compression TherapyVolume 33, Number 5
participants agreed to receive 15 chiropractic treatments,
without charge, at a rate of 3 times a week, and written
informed consent was obtained from each participant. The
exclusion criteria included past surgery to the shoulder,
injection to the shoulder in the month preceding the trial, a
diagnosis of rheumatoid arthritis or any other systemic
disorders affecting the joints, local tumors or infections, and
acute bursitis or capsulitis of the shoulder. Pain from a
herniated cervical disk may not only radiate sharply into the
trapezius and shoulder area but also all the way down to the
hand, causing numbness and tingling.
28
In our study,
shoulder pain was deemed to be referred from the spinal
structures if it was activated by active neck movement
(flexion, rotation, and lateral flexion),
29
and subjects with
such presentation were excluded from the trial.
Outcome Measures
Shoulder pain and related disabilities were measured
using the Shoulder Pain and Disability Index (SPADI)
questionnaire. This consists of a self-administered ques-
tionnaire, grouping 13 questions, 5 of which measure the
severity of pain caused by various arm movements
involving the shoulder, the pain being assessed on a
numeric pain scale ranging from 0 to 10. Eight additional
questions related to functional impairments of the shoulder
are assessed with a numeric scale.
30
The SPADI questionnaire has provided good psycho-
metric values with a test-retest reliability of total and
subscale scores ranging from 0.6377 to 0.6552. Internal
consistency ranged from 0.8604 to 0.9507.
31,32
Patients
perceived improvement was also measured using a
numerical scale from 0% to 100%. Some authors have
suggested that pain and disability questionnaires may be
the most valid form of outcome measurement in the
treatment of shoulder pain.
30,31
Randomization
Randomized allocation of the participants was managed
by an independent research assistant. Upon recruitment,
each participant was assigned a random allocation number
generated from a 2/3-1/3 random table, two thirds being
even numbers and 1/3 odd numbers, jumbled together in an
opaque envelope. The assistant pulled a number and
assigned the patient to either the experimental group or
the control group. The patient was not aware whether he
was in the experimental or in the control group.
Sixty-three patients met the inclusion requirements, but
because of transportation problems, 4 of them did not
complete the initial 15 treatments. Forty-one participants in
the experimental group and 18 in the control group
completed the questionnaires at different intervals. In the
experimental group (n = 41), data from the SPADI
questionnaire was collected at baseline, after 15 treatments,
30 days after the treatments, and 6 months later. The
patients perceived improvement score was obtained after 15
treatments, 30 days after the treatments, and 6 months later.
For the control group (n = 18), data from the SPADI
questionnaire was obtained at baseline and after the initial
15 treatments. The patients perceived improvement ques-
tionnaire was also filled after 15 treatments. For the
crossover group (n = 16), the SPADI and the patients'
perceived improvement questionnaires were filled out after
the 30 treatments (15 control + 15 experimental). Both
questionnaires were mailed to the experimental group 6
months after the last treatment.
Clinical Interventions
The experimental treatment consisted of a 15-second
thumb pressure (one thumb on the other) on myofascial
trigger points located in the following muscles and tendons:
the supraspinatus muscle, the deltoid muscle, the infra-
spinatus muscle, and the biceps tendon (Fig 1).
33
The
pressure was applied only to hyperirritable trigger points; if
there was none in 1 of these 4 areas, there was no treatment
on that area.
Trigger points were treated using a light pressure,
which was gradually increased to the participant's
maximum pain tolerance level. The pressure was painful
but bearable. The control treatment consisted of 15-
second pressure on trigger points located in muscles of
the cervical and upper dorsal areas. The authors suspected
that this control treatment had no influence on the
shoulder pain. The pressure also had to be painful but
bearable. Sixteen patients of the control group agreed to
receive 15 more experimental treatments. All the treat-
ments were given by the same experienced chiropractor
(GH). The patients were invited to stop taking any
analgesic medication as soon as possible. A flowchart
describing the clinical trial is presented in Figure 2.
Statistical Analysis
Results were analyzed according to the “intention to
treat”approach. Questionnaire scores of the experimental
group and control group (including the crossover) were first
submitted to a repeated measure 1-way analysis of variance
(ANOVA) (time intervals). When a main effect of time
intervals was observed for the experimental group, post hoc
comparisons were performed using Tukey tests. The
questionnaire scores were then submitted to a repeated
measure 2-way ANOVA (group × time intervals). This
analysis tested for the main effect treatment (experimental
or control), the main effect of time intervals (baseline
evaluation and after 15 treatments), and the interaction. A
ttest for independent samples was used to compare
the patients perceived amelioration percentage after 15
364 Journal of Manipulative and Physiological TherapeuticsHains, Descarreaux and Hains
June 2010Ischemic Compression Therapy
treatments. Statistical significance was set at Pb.05 for
all analyses.
RESULTS
Fifty-nine patients were assessed and treated between
September 2003 and December 2006. Patients' character-
istics at baseline evaluation were similar in both groups
(independent ttest, PN.05); see Table 1. The mean scores
and standard deviations for the SPADI questionnaire are
presented in Table 2. A significant group × time interval
interaction was observed (F
1, 57
= 9.8; P= .003) after the
first 15 treatments indicating that the experimental group
had a significant reduction in their SPADI scores compared
with the control group. A main significant effect of time
intervals was also observed in the experimental group for
Fig 1. Trigger points treated in this study. (Reprinted with permission from the Journal of the Canadian Chiropractic Association.
33
)
365Hains, Descarreaux and HainsJournal of Manipulative and Physiological Therapeutics
Ischemic Compression TherapyVolume 33, Number 5
the SPADI questionnaire (F
3, 114
= 49.88; Pb.001), and
post hoc analysis revealed a significant decrease of SPADI
scores after 15 treatments. This reduction in SPADI scores
was still present after 6 months (Tukey Pb.001). Figure 3
illustrates the results of the SPADI questionnaire for the
experimental group.
The patients perceived percentages of amelioration are
presented in Table 3. The ttest for independent samples
yielded a significant difference between the 2 groups (Pb
.001). The experimental group scored 74.5% (21.7) after 15
treatments, whereas the control group scored 28.9% (27.4).
For the experimental group, the mean percentage of
amelioration was 73.9% (28.5) 30 days after the treatments
and 66.3% (32.6) 6 months later. For the crossover group, it
was 78.9% (15.4) after receiving 15 placebo treatments +
15 experimental treatments.
Fig 2. Flowchart for study.
366 Journal of Manipulative and Physiological TherapeuticsHains, Descarreaux and Hains
June 2010Ischemic Compression Therapy
For the 16 patients who received 30 treatments (15
control + 15 experimental), the repeated measure 1-way
ANOVA yielded a significant difference between the
different time intervals, and post hoc analysis revealed a
significant reduction of the SPADI scores after the last
15 treatments (experimental treatment). No significant
side effects were seen during or after treatments. Fifty-
nine of the 63 patients accepted at the beginning of the
trial have received the prescribed 15 treatments. Four
patients did not complete the initial treatments because
they had traveling problems.
DISCUSSION
There is growing interest within the chiropractic
profession concerning the management of soft tissue
disorders.
25
Ischemic compression of trigger points is one
of the most popular treatment methods used by chiroprac-
tors to treat myofascial pain.
3,25
Recent data indicate that
trigger points are treated by 91% of chiropractors.
3
Ischemic compression is also known as Nimmo technique,
trigger point therapy,oracupressure.
3
The most pathog-
nominic symptom of myofascial pain syndrome is the
presence of pressure-sensitive palpable nodules that
reproduce the chief complaint; they are called trigger
points.
34
Trigger points may be located in muscles,
ligaments, tendons, fascias, and articular capsules,
24
and
myofascial pain therapy using ischemic compression may
be beneficial for patients with low back pain,
35
shoulder
pain,
33
and fibromyalgia.
36
Multiple options exist for the treatment of shoulder pain
and disability, and Gimblett et al
37
have successfully treated
2 cases of calcification tendinitis of the shoulder, using
ultrasound, range of motion exercise, and cross-friction
massage of the supraspinatus tendon. Kozin
38
believes that
it is sometimes useful to inject steroids in tender points,
especially when more conservative approaches have failed.
Patients usually prefer natural approaches for shoulder pain.
In a trial comparing shock wave therapy vs conventional
surgery in the treatment of calcifying tendinitis of the
shoulder, most of the patients refused consent to being
randomly assigned to a surgical procedure, as long as there
still was the possibility of being treated nonoperatively with
shock waves.
18
An extensive review of the literature was performed by a
Logan Chiropractic College librarian to find clinical trials
where myofascial trigger points in the shoulder area were
treated to relieve shoulder pain. Only one was found. It was
carried out by Andersen and Parkin-Smith
39
who wanted to
observe the effect of cryotherapy combined with passive
stretching, and moist heat combined with passive stretch-
ing, respectively, on active myofascial trigger points of the
shoulder girdle. Each patient was treated 5 times within a
3-week period, with a 1-month follow-up assessment.
Thirty patients were equally randomized in 2 groups. Self-
administered questionnaires and objective testing were
used. Both groups showed an improvement that persisted
through the 1-month follow-up consultation.
Our own study shows a decline of 44 points in the
experimental group 30 days after the end of treatments.
Usually, a SPADI score decline of greater than 10 points is
highly significant for improved shoulder function.
32
Thus,
the results of the present study suggest that ischemic
compression therapy around the shoulder may be an
effective treatment.
Limitations
Limitations of this study include the unequal distribution
of subjects over the 2 groups. This 2/3-1/3 randomization
strategy was used for ethical reasons as we wished for a
maximum number of subjects to be included in the
experimental treatment group. Cointervention was not
accounted for after the 15th treatment because all control
group participants were offered 15 experimental treatments
after the control treatments. This strategy was chosen
because the authors did not wish to let these patients go
without offering them the opportunity of receiving the
experimental treatments. Having only one treating doctor,
there could be a practitioner bias. The sample size is rather
small. Our control group is not really a placebo group even
if treating the latent trigger points of the neck and upper
thoracic by ischemic compression was quite unrelated to the
shoulder pain, especially because, from the beginning, the
patients with cervical pain radiating to the shoulder were
excluded. This control treatment was seen as highly
plausible by the patient.
In the experimental and the control groups, the mean
duration of pain was, respectively, 4 and 4.9 years, and thus,
one cannot assume that the pain would have ceased without
treatments over the following months. In the experimental
group, 35 of 41 or 85% of the participants felt an evident
amelioration within 6 treatments. Either they spontaneously
said so or they were asked at the sixth treatment.
Further studies are needed to examine the cost-
effectiveness of this approach and how ischemic compres-
sion compares to physiotherapy, pharmaceutical interven-
Table 1. Characteristics of assessable subjects: pretreatment
values
Experimental group
(n = 41)
Control group
(n = 18)
Men 21 5
Women 20 13
Mean age 46.5 (8.8) 45.6 (7.4)
Mean duration of symptoms (y) 4.0 (3.9) 4.9 (4.2)
Right shoulder involved 26 10
Left shoulder involved 15 8
Baseline SPADI questionnaire 67 (25.3) 71.5 (24.1)
367Hains, Descarreaux and HainsJournal of Manipulative and Physiological Therapeutics
Ischemic Compression TherapyVolume 33, Number 5
tion, and placebo treatment. These studies should include a
larger patient population, longer term follow-up, many
clinicians, and a blinded evaluator. Pre and postorthopedic
tests could be used.
CONCLUSION
The results of this trial suggest that myofascial therapy
using ischemic compression on trigger points on different
sites surrounding the shoulder may reduce the symptoms of
patients with chronic shoulder pain. In this trial, a decline of
44 points in the SPADI questionnaire is highly significant
when we consider that, in the literature, anything in excess
of a 10 points decline is already highly specific for
improved shoulder function. The authors hope that this trial
will encourage practitioners to treat myofascial trigger
points in cases of shoulder pain and to promote future
research in that field.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
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Table 3. Mean (SD) score from the patients perceived amelioration
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369Hains, Descarreaux and HainsJournal of Manipulative and Physiological Therapeutics
Ischemic Compression TherapyVolume 33, Number 5
