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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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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
treatapproach. 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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369Hains, Descarreaux and HainsJournal of Manipulative and Physiological Therapeutics
Ischemic Compression TherapyVolume 33, Number 5
... However, because in the crossover phase of this study it was not possible to randomize, we used only the data presented until the crossover phase. 33 Therefore, for this study the data are only presented until randomization of the individuals. ...
... The total number of individuals in all studies was 242, ranging from 30 participants 34 to 59 participants. 33 The intervention time ranged from a single session 34 to 3 sessions per week for 12 weeks. 33,35,36 The individuals' ages ranged from 18 years (minimum age) to 65 years (maximum age). ...
... 33 The intervention time ranged from a single session 34 to 3 sessions per week for 12 weeks. 33,35,36 The individuals' ages ranged from 18 years (minimum age) to 65 years (maximum age). 36 The maximal time duration of complaints was more than 5 years. ...
Article
Objective To systematically review current literature to determine the effectiveness of the ischemic compression (IC) technique on pain and function in individuals with shoulder pain. Methods This review was conducted according to recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Cochrane Collaboration for Systematic Reviews; a search was performed in the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Physiotherapy Evidence Database, and Web of Science. Randomized clinical trials and quasi-randomized clinical trials were included, and the methodological quality was evaluated through the Physiotherapy Evidence Database scale. Results The search found 572 studies; of these, 71 were selected by title and, subsequently, 29 were selected through abstract analyses. After critical analyses, 5 studies were included. The methodological quality ranged from 4 (reasonable) to 9 (excellent) points. Pain was assessed by all studies using the visual analog scale, Global Perceived Effect scale, Numerical Rating Scale, pressure pain threshold, or Perceived Amelioration Numerical Scale. Function was evaluated by 3 studies through the Shoulder Pain and Disability Index; Neck Disability Index; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment; and Disabilities of the Arm, Shoulder, and Hand questionnaires. The studies showed that the IC technique produces immediate and short-term positive effects for pain, and positive short-term effects for shoulder function in individuals with shoulder pain. Conclusion The IC technique seems to be beneficial for pain and shoulder function. However, caution is needed when considering this evidence owing to the limited quality of some studies, the few articles found, and the lack of standardization of the application parameters of the technique to facilitate its reproducibility.
... Myofascial trigger points (MTrPs) are specific tender spots and produce symptoms of myofascial pain (Bron et al. 2011). Studies have emphasized the presence of MTrPs in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles (Hains et al. 2010;Makhni et al. 2015). Patients with rotator cuff pathologies have a higher tendency to develop MTrPs than individuals without rotator cuff pathologies (Suh et al. 2014). ...
Article
Full-text available
Purpose To compare the ischaemic compression (IC) and instrument-assisted soft tissue mobilization (IASTM) in the treatment of MTrPs in addition to standard rehabilitation program in patients with rotator cuff tears. Methods Participants with rotator cuff tears were included the study (n = 46). Patients were randomly divided into two groups; which were Group 1 (IC + standard rehabilitation program (n = 23)), and Group 2 (IASTM + standard rehabilitation program (n = 23)) groups. Pain were assessed by visual analog scale (VAS). Range of motion (ROM) was assessed by a universal goniometer. Active MTrPs were assessed according to the Travel and Simons criteria. Pressure pain threshold (PPT) were assessed by a digital algometer. Function were evaluated by the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) and American Shoulder and Elbow Surgeons Standardised Shoulder Assessment (ASES) Form. Anxiety and depression were evaluated by the Hospital Anxiety and Depression (HAD) scale. Satisfaction was assessed by the Global Rating of Change scale after 6 weeks treatment. Results After the treatment, pain, ROM and the DASH, ASES, HAD scores improved in both groups (p < 0.05). The active MTrPs of 2 muscles, PPT of 4 muscles and DASH in Group 1 significantly improved compared to Group 2 (p < 0.05). Conclusion Although patients with low functionality accumulated in the IC group, the IC is more effective than the IASTM in increasing the PPT and functional improvement according to the results of the DASH score.
... The results showed that all treatments demonstrated a decline in pain perception. In addition to Hains et al., [19] who examined the effect of MTpR using ischemic compression on shoulder trigger points in patients with chronic shoulder pain. They found it effective in decreasing functional disability in the shoulder joint. ...
Article
Background/objective: The intent of the current study was to compare the immediate effects of positional release therapy (PRT) and manual trigger point release (MTpR) on neck range of motion and pain in upper trapezitis. Materials and methods: Sixty participants with upper trapezius myofascial trigger points (MTrPs)' participated in this study. Subjects were randomly classified into two groups (30 in each group): the subjects in Group A received PRT in a shortened position while those in Group B received MTpR in the neutral position for the upper trapezius muscle. They received four therapy sessions every day for four days. The pain intensity and range of motion were measured using the Numerical Pain Rating Scale (NPRS) and cervical range of motion (CROM), respectively, before treatment sessions and repeated immediately after the first and fourth treatment sessions in each group till the last day of their interventions. Results: Paired and unpaired t-Test was used for the data analysis. Pre- and postinterventional effects measured on each day and between groups, revealed that CROM and NPRS values were significantly improved in (MTpR) group (CROM, and NPRS P < 0.05). Conclusion: Both groups (PRT and MTpR) showed an increase in range of motion on CROM and a decrease in pain intensity on the NPRS during four sessions of therapy, but MTpR showed to be more effectual in these participants.
... Se realizaron dos técnicas de compresión isquémica a los 15 sujetos que componían este grupo. Una de las técnicas fue aplicada en un PGM central del supraespinoso (figura 12A), y la otra en un PGM central del infraespinoso (figura 12B), siendo estos dos músculos objeto de terapia en la mayoría de estudios consultados (98)(99)(100)(101)(102)(103)106). Las dos técnicas se realizaron en una posición de decúbito prono. ...
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.
... The compression should last at least 30 seconds without exceeding the patient's pain tolerance limit. The compression aims to stop the blood flow locally, to rekindle the blood flow to the affected tissue after its release [34]. This technique helps to deliver nutrients to the tissues, so tissue healing becomes faster [35]. ...
Article
Full-text available
One of the most common chronic musculoskeletal pain syndromes is myofascial pain syndrome (MPS). Trigger points (TrPs) are hypersensitive taut bands that appear in two genres, each with a different ratio in specific areas of the muscles, and when triggered, they can produce pain, numbness, and tingling. Various underlying causes (mechanical, nutritional, and psychological) have been discovered to participate in the pathogenesis of MPS, activating trigger points and intensifying the pain. Furthermore, genetic, social, and psychological factors seem to exacerbate these patients' clinical appearance, according to the biopsychosocial model, which seems to be closely linked to the formation of trigger points. Chronic pain and psychological distress frequently coexist, and psychological and social factors have been found to worsen the patient's quality of life and perpetuate the existing pain. The diagnosis is formed following a comprehensive physical and clinical examination, and the appropriate management technique is selected. For MPS treatment, management techniques based on the biopsychosocial model are used in conjunction with various myofascial release strategies and pharmacologic care. Exercise, posture correction, and a vitamin balance in the diet, especially in the Vitamin B complex, appear to prevent trigger point (TrP) activation. The precise etiology of MPS is not clear yet, and further research is needed to determine the root cause. A holistic approach, which blends the basic clinical care with the management of the biopsychosocial model, is essential to patients with MPS to regain their function and improve their quality of life and wellbeing.
... Some previous studies have analyzed the effectiveness of ischemic pressure 45,46,[54][55][56][57][58] and muscle energy techniques 49,59,60 in the treatment of latent MTrPs in the neck and shoulder regions. All these studies have found that ischemic pressure induced an increase in PPT levels over the MTrPs, which is in agreement with our results. ...
Article
Full-text available
Objective The purpose of this study was to investigate the effects of ischemic pressure (IP) vs postisometric relaxation (PIR) on rhomboid-muscle latent trigger points (LTrPs). Methods Forty-five participants with rhomboid-muscle LTrPs were randomly assigned into 3 groups and received 3 weeks of treatment—group A: IP and traditional treatment (infrared radiation, ultrasonic therapy, and transcutaneous electrical nerve stimulation); group B: PIR and traditional treatment; and group C: traditional treatment. Shoulder pain and disability, neck pain and disability, and pressure pain threshold (PPT) of 3 points on each side were measured before and after treatment. Results Multivariate analysis of variance indicated a statistically significant Group × Time interaction (P = .005). The PPT for the right lower point was increased in group A more than in groups B or C. Neck pain was reduced in group B more than in group C. Moreover, shoulder and neck disability were reduced in both groups A and B more than in group C. The PPTs of the left lower and middle points were increased in group B compared with groups A and C. The PPT of the left upper point was increased in group A more than in group C. There were significant changes in all outcomes in the 2 experimental groups (P < .05). No changes were found in the control group except in pain intensity, shoulder disability, and PPT of the left lower point. Conclusion This study found that IP may be more effective than PIR regarding PPT, but both techniques showed changes in the treatment of rhomboid-muscle LTrPs.
... There is evidence that ICT reduces pain symptoms (22), increases passive ROM (19) and strength (21,23) in individuals with non-traumatic painful shoulder conditions; however, these studies have not evaluated the effect of ICT on pain during mobility and the performance of maximum strength. In addition, although these studies have used the mobility and strength variables to assess the effect of treatment on MTPs, it is not yet known how these variables, as well as MTPs, react through their own assessments. ...
Preprint
Full-text available
Background: The myofascial trigger points (MTPs) may be associated with in shoulder dysfunction. Objective: To evaluate the immediate effect of ischemic compression therapy (ICT) and to verify the effect of the evaluation protocol on MTPs, pain, mobility and strength of shoulder. Methods: 15 individuals were assessed for the amount of MTPs, pressure pain threshold (PPT), range of motion (ROM), isometric strength of shoulder muscles and pain in performing these tests. The evaluations took place 48 hours before the ICT, immediately before, and after the ICT. Results: There was a reduction in the total amount of MTPs (p<0.01; Cliff’s d=0.24-0.35) and an increase in the PPT in the middle deltoid muscle (p=0.03) in the comparisons pre and post treatment, while there was no difference in ROMs and strength measures (p>0.05). The pain was less during the sagittal elevation ROM (p<0.01; d=0.80) and internal rotation (p=0.05; d=0.57), and during the performance of strength in arm elevation and external rotation (p=0.01; d=0.72 and d=0.68). There was generally no difference in the variables assessed between baseline and pre-treatment (p>0.06). Conclusion: The ICT immediately reduced the amount of MTPs and pain during mobility and strength. The evaluation protocol did not influence the studied variables. Trial registration: ReBEC (RBR-3DDG2K). Registered in July 5th, 2017 – Retrospectively registered, http://www.ensaiosclinicos.gov.br/rg/RBR-3ddg2k/.
Chapter
Myofascial trigger points (MTrPs), which are sensitive spot located taut bands in the muscle, are potential causes of musculoskeletal pain. Epidemiological studies showed significant relationships between presence of MTrPs and musculoskeletal pain in the neck, shoulder, low back, knee, etc., and the relationships between presence of MTrPs and disability in the life. These findings suggest that MTrPs may not only cause musculoskeletal pain, but also modulate (enhance) pain induced by primary organic disorders. Recent clinical trial studies reported that compression at MTrPs, which is one of manual therapy techniques, is effective to ameliorate musculoskeletal pain in various parts of the body. This chapter discusses beneficial effects of compression at MTrPs on musculoskeletal pain, and underlying mechanisms of MTrP compression effects.
Article
Full-text available
Several studies have shown that gastrocnemius is frequently injured in triathletes. The causes of these injuries are similar to those that cause the appearance of the myofascial pain syndrome (MPS). The ischemic compression technique (ICT) and deep dry needling (DDN) are considered two of the main MPS treatment methods in latent myofascial trigger points (MTrPs). In this study superficial electromyographic (EMG) activity in lateral and medial gastrocnemius of triathletes with latent MTrPs was measured before and immediately after either DDN or ICT treatment. Taking into account superficial EMG activity of lateral and medial gastrocnemius, the immediate effectiveness in latent MTrPs of both DDN and ICT was compared. A total of 34 triathletes was randomly divided in two groups. The first and second groups (n = 17 in each group) underwent only one session of DDN and ICT, respectively. EMG measurement of gastrocnemius was assessed before and immediately after treatment. Statistically significant differences (p = 0.037) were shown for a reduction of superficial EMG measurements differences (%) of the experimental group (DDN) with respect to the intervention group (ICT) at a speed of 1 m/s immediately after both interventions, although not at speeds of 1.5 m/s or 2.5 m/s. A statistically significant linear regression prediction model was shown for EMG outcome measurement differences at V1 (speed of 1 m/s) which was only predicted for the treatment group (R2 = 0.129; β = 8.054; F = 4.734; p = 0.037) showing a reduction of this difference under DDN treatment. DDN administration requires experience and excellent anatomical knowledge. According to our findings immediately after treatment of latent MTrPs, DDN could be advisable for triathletes who train at a speed lower than 1 m/s, while ICT could be a more advisable technique than DDN for training or competitions at speeds greater than 1.5 m/s.
Article
Objective: To conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019. Methods: MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points", "trigger point", "myofascial trigger point", "myofascial trigger points", "myofascial pain" and "myofascial pain syndrome". The MeSH keywords were combined by using Boolean operators "OR"/"AND". All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least one active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines. Results: Of 478 possibly relevant publications, 198 met our inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the six criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness", "referred pain" and "local twitch response" (n=28 studies, 22%). Conclusions: A noteworthy number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain and local twitch response were the three most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature. Registry: This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.
Article
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Objective. Assessment of the long-term course of shoulder complaints in patients in general practice with special focus on changes in diagnostic category and fluctuations in the severity of the complaints. Design. Prospective descriptive study. Setting. Four general practices in The Netherlands. Method. All patients (101) with shoulder complaints seen in a 5 month period were included. Assessment took place 26 weeks and 12–18 months after inclusion in the study with a pain questionnaire and a physical examination. Results. A total of 51% of the patients experienced (mostly recurrent) complaints after 26 weeks and 41% after 12–18 months. Diagnostic changes were found over the course of time, mostly from synovial disorders towards functional disorders of the structures of the shoulder girdle, but also the other way round. Although 52 of the 101 patients experienced complaints in week 26, 62% of those patients considered themselves 'cured'. After 12–18 months, 51% of the 39 patients experiencing complaints felt 'cured'. Conclusion. Many patients seen with shoulder complaints in general practice have recurrent complaints. The nature of these complaints varies considerably over the course of time, leading to changes in diagnostic category. Because of the fluctuating severity of the complaints over time, feeling 'cured' or not 'cured' is also subject to change over time.
Article
A shoulder pain and disability index (SPADI) was developed to measure the pain and disability associated with shoulder pathology. The SPADI is a self-administered index consisting of 13 items divided into two subscales: pain and disability. Thirty-seven male patients with shoulder pain were used in a study to examine the measurement characteristics of the SPADI. Test-retest reliability of the SPADI total and subscale scores ranged from 0.6377 to 0.6552. Internal consistency ranged from 0.8604 to 0.9507. SPADI total and subscale scores were highly negatively correlated with shoulder range of motion (ROM) supporting the criterion validity of the index. Principal components factor analysis with and without varimax rotation supported the construct validity of the total SPADI and its subscales. High negative correlations between changes in SPADI scores and changes in shoulder ROM indicated the SPADI detected changes in clinical status over short time intervals. The SPADI should prove useful for both clinical and research purposes.
Article
Current knowledge of the clinical course and efficacy of treatment for shoulder pain comes mainly from studies of hospital patients. However, only a few patients experiencing such pain require referral to a specialist. Although shoulder pain is common in the general population, the outcome of patients presenting in general practice is unknown.1 We conducted a prospective cohort study to determine the outcome of shoulder pain in primary care. Twelve general practitioners recruited 166 patients who consulted with a new episode of shoulder pain during one year. They recorded demographic information, diagnosis, management, and an assessment of passive elevation of the shoulder; patients assessed the disability associated with their symptoms with a validated 22 item disability questionnaire.2 To assess outcome, identical disability questionnaires were sent to patients six and 18 months after consultation, together with a question measuring self assessed change in symptoms …
Article
The effect of triamcinolone subacromial bursa injection versus naproxen therapy was compared in a randomized, double-blind, placebo-controlled study of 100 patients who had painful shoulders. Outcome was compared using degree of active abduction, pain, limitation of function, and a clinical index that combined equally weighted measures of all of these. In a time-adjusted analysis, triamcinolone was superior to placebo in all clinical variables. Naproxen was superior to placebo in all variables except pain. Triamcinolone was superior to naproxen in the relief of pain (P = 0.04) and the clinical index (P = 0.04). Multiple linear regression analysis showed that naproxen and triamcinolone treatment accounted for only 16% of the variation in outcome, compared with 44% accounted for by the clinical index prior to treatment. Thus, patients with a poor pretreatment clinical index (those with the most room for improvement) were least likely to improve. We conclude that both triamcinolone (P = 0.00005) and naproxen (P = 0.02) are superior to placebo in the treatment of the painful shoulder.