Figure 13.5 The pattern of pain referral from a trigger point ( 䉱) in the anterior part of the deltoid muscle. the acromioclavicular joint that lies underneath
the proximal attachment of the anterior part of this muscle. This injury, common in rugby players, is characterized by pain and tenderness localized to the shoulder tip and there are of course no TrPs to be found in the deltoid muscle itself.
Myofascial trigger point therapy is a manual technique that involves applying pressure to a trig- ger point to release the pathologic contraction of the muscle segment and to stretch that segment in order to restore normal muscle fiber length. The duration of treatment varies from person to person, but an initial course is usually manual therapy twice a week for three to four weeks. To be effective, trigger point therapy must be performed by a physical therapist skilled in manual therapy with myofascial release techniques. 61 Traditional physical therapy that ini- tially involves vigorous exercise and traction often does not help and sometimes causes the symptoms to worsen. In addition, acupuncture, stress manage- ment, and relaxation techniques, when combined with myofascial release therapy, can help patients ease the pain caused by MFTPs. 62
Active MTPs contribute significantly to the regional acute and chronic myofascial pain syndrome [2,3], such as lateral epicondylalgia , headache and mechanical neck pain  and temporomandibular pain disorders . Active MTPs are also the main peripheral pain gen- erator in generalized musculoskeletal pain disorders , such as fibromyalgia and whiplash syndrome [7,8]. MTPs are the targets for acupuncture and/or dry need- ling  and other pain therapies. Indeed, MTP anesthe- tization decreases both pain intensity and central sensitization in local pain and generalized pain condi- tions [8,10,11]. Two reviews have been published recently focusing on the current state of knowledge of myofascial pain syndrome associated with MTPs [12,13]. New evidence has emerged suggesting an important role of spontaneous electrical activity (SEA) at MTPs in the induction of muscle pain and central sensitization. This article reviews the literatures in the last decade about the SEA at MTPs; in particular, how SEA contributes to the induction of local and referred pain and how active MTPs are involved in the transition from the localized pain to generalized pain conditions.
INTRODUCTION symptoms . The actions taken at present to relieve the Shoulder pain is one of the most common approaches such as advice, analgesics, non-steroidal complaints affecting the locomotor apparatus, anti-inflammatory drugs, steroid injections and accounting for 5% of all general medical practice physiotherapy [4, 5]. A wide array of physiotherapy consultation . It is associated with significant methods are used to treat shoulder disorders including financial costs to the individual and to the community. thermotherapy, therapeutic ultrasound, transcutaneous Many workers with chronic shoulder pain which has electrical nerve stimulation (TENS), acupuncture, laser proved resistant to treatment are unable to resume full- and therapeutic exercises [6-10]. An alternative approach time work . In a minority of patients, shoulder pain to the management of persons with shoulder problems originate from specific or generalized conditions, such as consists of a treatment aimed at inactivating myofascial stroke, polyneuropathy, multiple sclerosis, rheumatoid triggerpoints (MTrPs) and eliminating factors that arthritis, polymyalgia, ankylosing spondylitis, or from perpetuate them . In reviews addressing the efficacy malignancies or referred pain from the neck or internal of interventions in shoulder patients, MtrPs therapy organs . It is evidenced mainly by pain, restricted and myofascial pain are rarely mentioned. However, movement and strength and by loss of shoulder some published case studies suggested that functionality . Localized soft tissue impairment is treatment of MtrPs in shoulder patients may be considered to be the most common source of these beneficial [11-13].
pain (>6mos) were included in this study. Diagnoses ranged from low back pain, individuals post surgical spine surgery, recurrent thrombophlebitis, and herpetic neuralgia. Two outcome instruments were administered at baseline to assess pain (Global Pain Estimate) and function (North Carolina Pain Clinic Performance Profile). The Global Pain Estimate requires the subject to rate pain on a scale of 1-100 and the North Carolina Pain Clinic Performance Profile is a Likert type scale designed to asses deficits in 8 functional items such as work, sleep, and daily activities. Subjects were randomly assigned to receive either traditional acupuncture or needling to tender musculoskeletal areas. Intervention was provided once a day for seven days with a two- day break between the 5 th and 6 th treatment. The reported results included 9 subjects out
placebo-controlled study showed that needle acupuncture was an effective treatment but only provided a weak improvement in quality of life (Karst et al., 2001). Acupressure, a technique derived from acupuncture, is another treatment modality of traditional Chinese medicine and has been used for centuries in Asian areas including China, Japan, and Korea and other countries for relieving pain, illness, and injury (Mills, 2001). Acupressure, which uses fingers instead of needles at the acupoints, is an effective, non-invasive, supportive treatment for multiple clinical complaints, and has limited side effects. Its effectiveness in reducing lower back pain has been documented (Hsieh et al., 2004). However, the efficacy of acupressure in reducing headache has never been demonstrated by a randomized con- trolled clinical trial. Therefore, the aim of this study was to compare the efficacy of acupres- sure with that of a muscle relaxant together with analgesic medication in reducing chronic headache.
The hallmark of PAS is decreased range of motion and shoulder pain. There often idiopathic cause or trigger. The pain is often described as a poorly localized and deep ache. If the pain is localized, it is usually in the area of the anterior or posterior capsule. It may radiate to the biceps with progressive pain and stiffness when performing flexion, abduction and external rotation. Weakness is often correlated to pain or concomitant tendinopathy. Crepitus may be present on the involved side. Like other shoulder conditions pain may impair sleep. Unlike more serious causes of shoulder pain, otherwise it doesn‟t cause red flag symptoms such as high temperature, perfuse perspiration and weight loss. Neuropathic symptomslike numbness and altered sensation in the hand may have differential diagnosis such as cervical radiculopathy.
Her chief complaint was a persistent dull pain in the region of the bilateral mandibular first molars. An X-ray examination revealed nothing of significance. Many taut bands and several tender points were found on the mas- seter, the temporalis, and the sternocleido- mastoid muscles accompanied by referred pain, however (Fig. 1). The patient reported sharp pain occurring from the left eye to the right occipital region when the usual pain became worse. She even reported vomiting when the tension headache in the temporalis muscles was particularly severe. Crowding was observed in the anterior teeth, together with anterior open bite (Fig. 2, 3). No other abnor- mality was observed in the oral cavity. The depth of the periodontal pockets was 2–3 mm, and no teeth mobility was observed. Maximal mouth-opening distance was as small as 10 mm.
TCM pattern diagnoses of both acupuncturists, and data obtained on the frequency of the united patterns for each participant. A participant was given a diagnosis if at least one acupuncturist had given the TCM pattern diagnosis. The same merging procedure was done for the acupunc- ture points. Additional analyses were performed to exam- ine whether the results differed when analysed for each acupuncturist separately.
Whereas the exact incidence of myofascial pain is unknown, Cummings and White (2001) identified 3 studies which reported MTrPs as a significant primary source of pain. Triggerpoints were claimed to be the primary cause of pain in 74% of 96 patients with musculoskeletal pain presenting to a community medical centre and in 85% of 283 patients admitted to a pain centre. In another study, 55% of patients referred to a dental clinic were reported to have MTrPs as the cause of their pain. Further research into the pathogenesis of MTrPs and clinical efficacy of treatment is warranted.
Another important source of deep tissue nociception is active myofascial triggerpoints (MTPs) in the neck and shoulder muscles, which are considered to be a primary source of pain following whiplash injury [18,19] as has been shown for other widespread pain syndromes such as fibromyalgia . MTPs may perpetuate lowered pain thresholds in uninjured tissues far away from their local- ization  and are one of the most important peripheral pain generators and initiators for central sensitization . Consequently, by treating MTPs, the dysfunctional process of the nervous system may be mitigated leading to clinical improvement ..
Acupuncture is one of the key components of the system of traditional Chinese medicine (TCM). In the TCM system of medicine, the body is seen as a delicate balance of two opposing and inseparable forces: yin and yang. Yin represents the cold, slow, or passive principle, while yang represents the hot, excited, or active principle. Among the major assumptions in TCM are that health is achieved by maintaining the body in a “balanced state” and that disease is due to an internal imbalance of yin and yang. This imbalance leads to blockage in the flow of qi (vital energy) along pathways known as meridians. It is believed that there are 12 main meridians and 8
One limitation concerns the fact that this is a single- center study. It does not lend the results to great generalizability to more diverse sets of patients in more diverse settings. Our directed acupuncture treatment is uniformly applied, and adjunctive therapies are not used. In addition, acupuncturists in diverse settings with dif- ferent philosophies, backgrounds, training, and clinical experiences might have chosen different technique for the directed acupuncture intervention. Therefore, the external validity can be somewhat hard to achieve. But we ensure that the risk of contamination between groups will be minimized, while maintaining the integrity of the experimental group comparison. As a result, whether the findings can be generalized to the clinical setting is unclear and more work is needed.
2010, Fernandez-de-Las-Penas et al., 2005, Rickards, 2006, Tough et al., 2009). The efficacy of manual techniques or modalities has been explored in clinical trials with poor internal validity (Fernandez-de-Las-Penas et al., 2005, Rickards, 2006, Cagnie et al., 2013). Thus, high quality randomized clinical trials on the efficacy of non-invasive treatment are required. Moreover, it is important to define which manual therapy techniques are the most appropriate to treat MTrPs. Regarding this issue, Simons, after the publication of the motor endplate hypothesis (Simons et al., 1999), proposed an original manual approach named “trigger point pressure release”. The author suggested that the classic heavy ischaemic compression of MTrPs should be avoided, in order to avoid tissue hypoxia. As an alternative, he proposed a passive muscle lengthening until tissue resistance, with a slow and gentle MTrP compression. The hypothesis was that pressing and stretching the tissue uncouples myosin from actin in the MTrP region, a process that usually requires ATP. The described manual technique may also release the ”stuck” spring function of the titin connection to the Z bands of the sarcomeres (Dommerholt and Huijbregts, 2011). The theory described is very interesting, although based on anecdotal evidence, and needs basic physiological research to be confirmed.
The presence of myofascial triggerpoints in upper Trape- zius muscle is one among the classical finding in neck pain individuals. The most typical symptoms include a pres- ence of taut band and hyperirritable tender spots within the muscle. Various treatment has been advocated namely trigger release, local injection, physical modalities, Cryo- therapy, dry needling, ischemic compression and other manual methods. The present experimental study reveals the importance of manual methods, soft tissue mobiliza- tion in treating myofascial triggers in upper trapezius mus- cle.
Figure 3 Graphical representation of MTrPs and IZ location in the upper trapezius according to the ACS in 48 subjects. A) Active MTrPs are represented as green circles and latent as white circles, and the colours indicate MTrP spatial densities (dark red spot indicates high trigger point density). B) IZ distribution, colour represents IZ density (dark blue area indicates high IZ density). C) Each IZ loction is represented by different colours link IZs detected on the matrix columns. AC, acromial angle; C7, spinous process of the seventh cervical vertebrae. Table 1 Summarised results (Continued)
Chineza./ Certain acupuncturepoints (Chinese: Certain acupuncturepoints (Chinese: 腧 腧 穴 穴 ; pinyin: shùxué or Chinese: ; pinyin: shùxué or Chinese:
穴 位 位 ; pinyin: xuéwèi, Japanese: ; pinyin: xuéwèi, Japanese: つ つ ぼ ぼ tsubo) are ascribed different functions tsubo) are ascribed different functions
according to different systems within the TCM framework. according to different systems within the TCM framework.
Background: 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 triggerpoints (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. Methods: 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.