Arch Phys Med Rehabil. 2008 Jun;89(6):1169-76.
A systematic, critical review of manual palpation for identifying myofascial
trigger points: evidence and clinical significance.
Myburgh C, Larsen AH, Hartvigsen J.
Institute of Sports Science and Clinical Biomechanics, University of Southern
Denmark.
[email protected]
OBJECTIVE: To determine the reproducibility of manual palpation in identifying
trigger points based on a systematic review of available literature. DATA
SOURCES: Medline (1965-2007), CINHAL (1982-2007), ISI Web of Science (1945-2007),
and MANTIS (1966-2007) databases and reference lists of articles. STUDY
SELECTION: 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. DATA EXTRACTION: 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. DATA SYNTHESIS: 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. CONCLUSIONS: 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.
Eur J Pain. 2008 Apr 3. [Epub ahead of print]
Acupuncture and dry needling in the management of myofascial trigger point pain:
A systematic review and meta-analysis of randomised controlled trials.
Tough EA, White AR, Cummings TM, Richards SH, Campbell JL.
Primary Care, Peninsula Medical School, Universities of Exeter and Plymouth, Room
N32, ITTC Building, Tamar Science Park, Plymouth PL6 8BX, UK.
Pain from myofascial trigger points is often treated by needling, with or without
injection, although evidence is inconclusive on whether this is effective. We
aimed to review the current evidence on needling without injection, by conducting
a systematic literature review. We searched electronic databases to identify
relevant randomised controlled trials, and included studies where at least one
group were treated by needling directly into the myofascial trigger points, and
where the control was either no treatment, or usual care; indirect local dry
needling or some form of placebo intervention. We extracted data on pain, using
VAS scores as the standard. Seven studies were included. One study concluded that
direct dry needling was superior to no intervention. Two studies, comparing
direct dry needling to needling elsewhere in the muscle, produced contradictory
results. Four studies used a placebo control and were included in a
meta-analysis. Combining these studies (n=134), needling was not found to be
significantly superior to placebo (standardised mean difference, 14.9 [95%CI,
-5.81 to 33.99]), however marked statistical heterogeneity was present
(I(2)=88%). In conclusion, there is limited evidence deriving from one study that
deep needling directly into myofascial trigger points has an overall treatment
effect when compared with standardised care. Whilst the result of the
meta-analysis of needling compared with placebo controls does not attain
statistically significant, the overall direction could be compatible with a
treatment effect of dry needling on myofascial trigger point pain. However, the
limited sample size and poor quality of these studies highlights and supports the
need for large scale, good quality placebo controlled trials in this area.
Clin J Pain. 2007 Mar-Apr;23(3):278-86.
Variability of criteria used to diagnose myofascial trigger point pain
syndrome--evidence from a review of the literature.
Tough EA, White AR, Richards S, Campbell J.
Peninsula Medical School, Universities of Exeter and Plymouth, UK.
[email protected]
OBJECTIVES: The aim of the literature review was to investigate the criteria
adopted by "experts" to diagnose myofascial trigger point (MTrP) pain syndrome.
Experts were defined as being either researchers investigating MTrP pain syndrome
or the "authority" the researchers cited as a source of reference for MTrP pain
syndrome diagnosis. METHODS: We searched electronic databases to identify
relevant empirical research (excluding studies not in English and those relating
to dental pathology). Of 607 possibly relevant publications 93 met our inclusion
criteria. We recorded (1) the individual criterion and criteria combinations used
to diagnose MTrP pain syndrome; (2) the cited "authoritative" publications and
(3) the criteria recommended by the authoritative publications as being essential
for MTrP pain syndrome diagnosis. RESULTS: The review identified 19 different
diagnostic criteria. The 4 most commonly applied criteria were: "tender spot in a
taut band" of skeletal muscle, "patient pain recognition," "predicted pain
referral pattern," and "local twitch response." There was no consistent pattern
to the choice of specific diagnostic criteria or their combinations. However, one
pair of criteria "tender point in a taut band" and "predicted or recognized pain
referral" were used by over half the studies. The great majority of studies cited
publications by Travell and more recently Simons as a principal authoritative
source for MTrP pain syndrome diagnosis, yet most of these studies failed to
apply the diagnostic criteria as described by these authorities. DISCUSSION: We
conclude that there is as yet limited consensus on case definition in respect of
MTrP pain syndrome. Further research is needed to test the reliability and
validity of diagnostic criteria. Until reliable diagnostic criteria have been
established, there is a need for greater transparency in research papers on how a
case of MTrP pain syndrome is defined, and claims for effective interventions in
treating the condition should be viewed with caution.
