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Literature review. Myofascial Pain Syndrome: Trigger Points. JMP 20(4) 2012

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DOI: 10.3109/10582452.2012.741189

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 Journal of Musculoskeletal Pain, Vol. 20(4), 2012
© 2012 Informa Healthcare USA, Inc.
ISSN: 1058-2452 print / 1540-7012 online
DOI: 10.3109/10582452.2012.741189

LITERATURE REVIEW

Myofascial Pain Syndrome: Trigger Points

Jan Dommerholt, PT, DPT, MPS1,2,3 and Carel Bron, PT, PhD4,5
1
Bethesda Physiocare/Myopain Seminars, Bethesda, MD, USA, 2Universidad CEU Cardenal Herrera, Valencia, Spain,
3
Shenandoah University, Winchester, VA, USA, 4Scientific Institute for Quality of Healthcare, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands, 5Private Practice for Physical Therapy for Neck, Shoulder and Upper Extremity
Disorders, Groningen, The Netherlands
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14

RESEARCH STUDIES and least pain during the past week, and the size and
location of the spontaneous and referred pain obtained
Fernández-de-Las-Peñas C, Gröbli C, Ortega-
from drawings on a body chart.
Santiago R, Fischer CS, Boesch D, Froidevaux P,
Both groups were comparable for all demographic
Stocker L, Weissmann R, González-Iglesias J:
and clinical data at baseline. There was a positive
Referred pain from myofascial trigger points in
linear correlation between the mean intensity of
head, neck, shoulder, and arm muscles reproduces
current pain and the worst level of pain experienced
pain symptoms in blue-collar (manual) and
in the preceding week [rs = 0.654; P = 0.0006],
white-collar (office) workers. Clin J Pain 28(6):
For personal use only.

but only in the blue-collar workers. No significant

511–518, 2012.
Summary
This study aimed to describe the prevalence of active
and latent trigger points [TrPs] in the neck and
shoulder muscles of a population of white-collar
[office] workers and blue-collar [manual] workers
and to assess whether the areas of spontaneous pain
were similar to the referred pain elicited by manual
examination of the TrPs. The temporalis, masseter,
upper trapezius, sternocleidomastoid, splenius
capitis, oblique capitis inferior, levator scapulae,
scalene, pectoralis major, deltoid, infraspinatus,
extensor carpi radialis brevis and longus, extensor
digitorum communis, and supinator muscles were
examined bilaterally by experienced assessors
blinded to the participants’ condition.
Sixteen blue-collar and 19 white-collar workers with
non-specific pain in the neck, shoulder, arm, and upper
back region were included. Subjects with a severe
medical comorbidity or a sign of mental depression
were excluded. Outcome measures were the number
of muscles with an active or latent TrP, the score on
an 11-point numerical rating scale for current, worst,
differences were found for the number of active or
latent TrPs, and no correlation was found between
the number of TrPs and any of the pain parameters.
Active TrPs were most prevalent in the upper trape-
zius, infraspinatus, levator scapulae, and extensor
carpi radialis brevis muscle. The largest referred
pain areas were those related to the pectoralis
major, infraspinatus, upper trapezius, and scalene
muscles. There were no significant correlations
found between the pain intensity, duration of the
symptoms, and the size of the referred pain area in
either group.
Comments
This study showed that the combined referred pain
patterns from active TrPs covered the overall spon-
taneous pain pattern, indicating the importance of
TrPs in patients with non-specific pain complaints.
Since no significant differences were found between
the two groups [white-collar versus blue-collar
workers], it is conceivable that workers in both
groups overuse the same muscles during work. This
study provides us with strong support in favor of
TrPs in the debate about the potential causes of

Address correspondence to: Dr. Jan Dommerholt, PT, DPT, MPS, Bethesda Physiocare/Myopain Seminars, 7830 Old Georgetown
Road, Suite C-15, Bethesda, MD 20814-2440, USA. E-mail: dommerholt@bethesdaphysiocare.com
Submitted: October 15, 2012; Revisions Accepted: October 15, 2012


  Dommerholt and Bron

non-specific complaints of the arm, neck, and
shoulders [CANS] (1). The importance of interven-
tions, including micro-breaks during work time,
increasing muscle awareness, and stress management,
remains extremely important to address perpetuating
factors of TrPs, but, as the authors suggested, inacti-
vating TrPs should be part of the management of
CANS (2). More studies like this are needed to
better understand CANS and musculoskeletal dis-
orders [CB].
Fernández-Pérez AM, Villaverde-Gutiérrez C,
Mora-Sánchez A, Alonso-Blanco C, Sterling M,
Fernández-de-Las-Peñas C: Muscle trigger points,
pressure pain threshold, and cervical range of
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
the active TrPs may play in central sensitization
following whiplash [JD].
Jarrell J, Giamberardino MA, Robert M, Nasr-
Esfahani M: Bedside testing for chronic pelvic
pain: discriminating visceral from somatic pain.
Pain Res Treat, 2011. Article ID 692102.
Summary
The objective of this study was to evaluate three easy
bedside tests in discriminating visceral pain from
somatic pain in women with chronic pelvic pain.
Eighty-one women [mean age 33.9 ± 1.2] with
chronic pelvic pain participated in the study. The sub-
jects were examined for cutaneous allodynia using a

motion in patients with high level of disability

cotton-tipped culture stick drawn from the upper
related to acute whiplash injury. J Orthop Sports
abdomen into the region of pain. According to the
Phys Ther 42(7): 634–641, 2012.
authors, this method of mapping out regions charac-
Summary terized by allodynia has a 98-percent interrater
reliability. Within the area of cutaneous allodynia,
This cross-sectional cohort study of 20 subjects with a
the subjects were examined for the presence of
high level of disability following an acute whiplash
TrPs. Nearly all cases presented with TrPs near the
injury focused on the presence of TrPs in the tempor-
junction of the external oblique and rectus abdomi-
alis, masseter, upper trapezius, levator scapulae, ster-
nus muscles. Lastly, subjects underwent a pain
For personal use only.

nocleidomastoid, suboccipital, and scalene muscles in

comparison with 20 age and sex-matched controls.
Subjects in the whiplash group had 7.3 ± 2.8 TrPs
[3.4 ± 2.7 were latent and 3.9 ± 2.5 were active]
compared to 1.7 ± 2.2 latent TrPs and no active
TrPs in the control group. When one TrP in a
muscle reproduced the subject’s pain complaint,
other potential TrPs in that muscle were not exam-
ined. Active TrPs were most observed in the levator
scapulae and upper trapezius muscles, and were
more prevalent with higher levels of neck pain,
chronicity, reduced range of motion, and higher
pain pressure sensitivity over the cervical spine at
the levels of C5 and C6.
Comments
This paper was published in one of the premier
United States physical therapy journals with an
impact factor of 3.000 in ISI’s Journal Citation
Reports for 2011. In the Discussion Section, the
authors discuss the possible clinical implications of
this study. One of the authors, Dr. Michele Sterling,
has published many previous papers on sensitization
following whiplash. The current paper suggests that
active TrPs may need to be considered in the
initiation and maintenance of central sensitization
following whiplash, which has been suggested before
by others (3–5). The authors did acknowledge
several limitations of the current study. All together,
this is an excellent first step in exploring the role
threshold evaluation using a Von Frey electro-
anesthesiometer. Since an application of 100 g of
pressure on the deltoid muscle did not produce any
pain response, this muscle served as a reference
point. Pain thresholds below 100 g were considered
as reduced pain thresholds. Measurements of pain
threshold were taken in the four abdominal quadrants
and in the perineal body.
Abdominal and perineal cutaneous allodynia and
abdominal TrPs were found to significantly discrimi-
nate visceral from somatic sources of pain
[P < 0.001], but perineal TrPs and reduced pain
threshold did not. A comparison of the reduction of
pain threshold did show that in the lower abdominal
quadrants, the women with visceral pain had signifi-
cantly lower thresholds than women with somatic
pain.
Comments
Several years ago, Dr. Jarrell indicated that abdominal
TrPs had a high predictive value of endometriosis (6).
This preliminary paper adds an important dimension
to the previous paper by showing that tests for
cutaneous allodynia are indeed highly indicative of
a visceral source of pain. Clinically, this is of great
importance. The tests described in this paper are
easy to apply without any significant financial
layout. Using these simple tests as part of the clinical
screening process can point the clinician and patient
 Myofascial Pain Syndrome: Trigger Points
into the right direction and avoid a plethora of
unnecessary and expensive measures [JD].
CLINICAL STUDIES
Benecke R, Heinze A, Reichel G, Hefter H, Göbel H:
Botulinum type A toxin complex for the relief of
upper back myofascial pain syndrome: how do
fixed-location injections compare with trigger
point-focused injections? Pain Med 12(11): 1607–
1614, 2011.
Summary
This German multicenter study of the efficacy and
tolerability of fixed injections of botulinum toxin
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
type A in patients with myofascial pain syndrome of
the upper back involved 154 patients who were ran-
domly assigned to a treatment or control group. Sub-
jects in the treatment group received 10 botulinum
toxin injections or placebo treatments in fixed
locations throughout the neck and shoulder region.
Subjects in the control group received saline injec-
tions. Physicians and patients were blinded. Injections
were administered at a depth of 1–2 cm using a 27-
For personal use only.
gauge 40 mm needle. The main outcome measure
was the proportion of subjects with mild or no pain
at five weeks. Secondary outcome measures were
changes in pain intensity, duration of pain, number
of pain-free days per week, duration of sleep, duration
of migraine and tension-type headache, time to a
reduction in pain, and the number and pain intensity
of TrPs which were quantified by a physician at each
of five visits. The physicians who administered the
injections also recorded the occurrence of adverse
events, vital signs, and documented patient/physician
global assessments of tolerability. One patient with-
drew from the study and five patients had no efficacy
data and were excluded from the efficacy population.
At week 5, 49 percent of the treatment group and
38 percent of the control group responded to treat-
ment, but the difference between the two groups did
not reach statistical significance. It was not until
week 8 that the treatment group showed significantly
more improvement than the control group. Differ-
ences in the duration of pain were significant at
weeks 9 and 10. There were no differences in
between the groups for duration of migraine of
tension-type headaches, or duration of sleep. At
week 4, subjects in the botulinum toxin group had
more days per week without pain. At week 12, the
number of TrPs reduced from approximately 10 to
9 in the treatment group. The pain intensity of TrPs
was lower in the treatment group from weeks 4 to
12. Both physicians’ and patients’ global assessment

of their conditions favored botulinum toxin at
weeks 8 and 12. Both groups had comparable rates
adverse events, but the nature of the rates of adverse
events did differ. Botulinum toxin patients experi-
enced mostly musculoskeletal, connective tissue, and
bone disorders [42 percent], whereas the control
group suffered mostly from infections and infesta-
tions [38 percent].
Comments
The title of this article is a bit misleading as the study
did not really compare injections at fixed locations
with more direct TrP injections. In this study, the
authors compared two different types of injections
at fixed locations. They did, however, compare the
results of the current study with the results of a
2006 study by the same group (7), which was pre-
viously reviewed in this column (8). The authors con-
cluded that fixed point injections with botulinum
toxin were not as effective after five weeks of treat-
ment as direct TrP injections. Over a longer period
of time, botulinum toxin injections may be beneficial
in the treatment of myofascial pain [JD].
Damian M, Zalpour C: Trigger point treatment
with radial shock waves in musicians with nonspe-
cific shoulder-neck pain: data from a special physio
outpatient clinic for musicians. Med Prob Perform-
ing Artists 26(4): 211–217, 2011.
Summary
Twenty-six musicians [16 women and 10 men;
average age: 26 with a range of 19–45 years of age]
with myofascial pain in the neck and shoulder
muscles were included in this randomized blinded
study of the effects of radial shockwave therapy on
pain levels, function, and quality of life. Outcome
measures included a pre- and post-questionnaire,
the Shoulder Pain and Disability Index, the Neck
Pain Disability Index Questionnaire, a Visual
Analog Scale [VAS], pressure algometry over TrPs,
cervical range of motion measurements, and a
posture assessment. Subjects were divided into an
intervention and a control group. Subjects in both
groups received a physical therapy program consisting
of massage and stretching. Subjects in the interven-
tion group also received one 25-minute session of
radial shock wave therapy over a period of five to
six weeks. Three subjects did not complete the study.
There was a short-term reduction of pain, but
there were no changes in cervical range of motion,
posture, and pressure algometry. There was a signifi-
cant improvement for the total in the Shoulder Pain
  Dommerholt and Bron
and Disability Index and Neck Pain Disability Index
Questionnaire scores.
Comments
This study from Germany does not show overwhelm-
ing support for using radial shockwave in the treat-
ment of TrPs. It should be noted that there are
differing opinions as to what constitutes shockwave
therapy. Some would argue that the unit used in
this study is actually a pulsewave machine and not a
true shockwave unit. There are not many studies of
shockwave therapy for TrPs, but some do show its
potential (9,10). The authors stated that shockwave
therapy would “purify the tissue and increase the
interaction between the central and peripheral
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
nervous systems” based on documentation provided
by the manufacturer of the shockwave equipment.
This reviewer is not aware of any research substantiat-
ing these claims [JD].
Itoh K, Asai S, Ohyabu H, Imai K, Kitakoji H:
Effects of trigger point acupuncture treatment on
temporomandibular disorders: a preliminary
randomized clinical trial. J Acupunct Meridian
For personal use only.
Stud 5(2): 57–62, 2012.
Summary
This single-blinded, randomized, sham-controlled
trial studied the effects of acupuncture needling of
masticatory and neck muscles in patients with tem-
poromandibular disorder compared to sham need-
ling. Sixteen students of an acupuncture school in
Japan were recruited. They were diagnosed with tem-
poromandibular joint disorder for at least six months,
had a Helkimo index of I or III, did not respond to
medications, and had not been treated with acupunc-
ture needling in the previous six months. They were
randomly assigned to either the treatment group or
the sham needling group. The subjects in the treat-
ment group were treated once a week during a five-
week period. Every session lasted for approximately
30 minutes. During these sessions, acupuncture need-
ling was performed in each TrP in the temporalis,
masseter, lateral pterygoid, digastric, sternocleido-
mastoid, trapezius, splenius capitis, or other relevant
muscle. The needle [diameter 0.3 mm, length
50 mm] was inserted at a depth of 5–15 mm into the
TrP, followed by a sparrow-like technique to elicit a
local twitch response [LTR] or a reasonable attempt
was made. Next, the needle was retained for
15 minutes. In the sham group, the same procedure
was used but with a cut and smoothed needle to
prevent the needle from entering the skin. All pro-
cedures were performed by a trained acupuncturist
with three years of clinical experience. To evaluate the
blinding procedure, the patients were asked to indicate
whether the needles entered the muscle, penetrated the
skin, or they were unable to choose between these
options. All patients indicated that they were treated
with needles entering the muscle, which means that
the blinding procedure was successful.
Primary outcome measures were pain intensity
during daily activities such as eating and talking
measured with a VAS for pain and oral function,
which was also assessed by measuring maximal
mouth opening. After two weeks, the VAS scores de-
creased significantly and clinically meaningful in the
treatment group, while the VAS scores in the sham-
group decreased only after four weeks and the differ-
ence was smaller. After 10 weeks, the effect was still
significant and clinical meaningful in the treatment
group, but not for the sham group. The maximal
mouth opening measurements were almost at the
normal range [men: 45–60 mm; women:
40–55 mm] and were not influenced.
Comments
Many studies that compare real versus sham needling
use a superficial needling technique for the sham
treatment. It is likely, however, that superficial need-
ling will still have some treatment effect, although
less than deep needling techniques. Any needling
may have a physiological effect, such as a release of
endorphins, a change in pain thresholds, or an
expectancy of a positive outcome (11,12). It is of
interest that in this study the sham needle did not
penetrate the skin and did not seem to have any need-
ling effect. In one study, tapping a von Frey filament
against the skin induced specific brain responses,
which suggested that tapping may not be a suitable
sham procedure either (13). Nevertheless, in this
study the participants who received the sham treat-
ment were all convinced that the muscle entered the
muscle. The small size of the study is a true limitation.
In the intervention group, one patient withdrew from
the study, because of a deterioration of the symptoms.
Since the authors did not present the raw data from
the study, it is not possible to look at the influence
that might have had on the outcome. There is a
need for larger studies to confirm the results of this
study. Another limitation is that only one LTR was
elicited, which is not consistent with common clinical
practice. It would be interesting to see whether the
number of elicited LTRs is correlated to the magni-
tude of the effect. Finally, all participants in this
study were students of an acupuncture school. The
knowledge of acupuncture, familiarity with the
“deqi” sensation commonly referred to in
 Myofascial Pain Syndrome: Trigger Points
acupuncture practice, and their confidence in the effi-
cacy of acupuncture may have introduced several
serious biases [CB].
Fernández-Lao C, Cantarero-Villanueva I, Fernán-
dez-de-Las-Peñas C, del Moral-Avila R, Castro-
Sanchez AM, Arroyo-Morales M: Effectiveness of
a multidimensional physical therapy program on
pain, pressure hypersensitivity, and trigger points
in breast cancer survivors: a randomized controlled
clinical trial. Clin J Pain 28(2): 113–121, 2012.
Summary
The aim of this randomized controlled trial was to
evaluate the effects of an eight-week multidimen-
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
sional physical therapy program on neck and
shoulder pain in breast cancer survivors with active
TrPs. Patients were recruited from a breast cancer
unit of a Spanish hospital and were eligible if they
had received a simple mastectomy or quadrantect-
omy, including those with [immediate or subsequent]
breast reconstruction, between 25 and 65 years of age,
had finished their co-adjuvant treatment except
hormone therapy, did not have active cancer, and
For personal use only.
had neck and shoulder pain that began after their
breast cancer surgery. Exclusion criteria were che-
motherapy or radiotherapy at the time of the study,
and chronic conditions that would not permit to
follow the physical program.
Patients were randomly assigned to either the
intervention group or the control group using a com-
puter-generated number sequence. The intervention
consisted of a total of 24 hours of individual training
and 12 hours of physical recovery procedures, con-
ducted three times per week for 90 minutes each.
During these sessions, the patients performed indi-
vidual aerobic training, including walking, stretching,
and strengthening exercises with particular attention
to the neck and shoulder regions. The physical train-
ing was followed by 30–40 minutes of muscle stretch-
ing and myofascial release techniques. The program
ended with a 10-minute free meditation. The
control group received the usual care as rec-
ommended by the oncologist, concerning nutrition,
healthy lifestyle, and exercise.
Primary outcome measures were pressure pain
thresholds [PPT] and a VAS for spontaneous pain.
An assessor blinded to the allocation of the partici-
pants assessed the PPT levels bilaterally over the
C5–C6 zygopophyseal joints, deltoid muscles,
second metacarpals, and tibialis anterior muscles.
An experienced assessor explored the presence of
TrPs bilaterally in the upper trapezius, sternocleido-
mastoid, levator scapulae, scalenes, pectoralis major,

and infraspinatus muscles. Out of 322 breast cancer
survivors, 44 were included. Both groups were com-
parable for all outcomes at baseline. Two patients in
the intervention group dropped out of the study,
because of oncological reasons. All patients showed
high adherence to the program and no adverse reac-
tions were reported. The intervention group showed
a significant decrease in neck and shoulder/axillary
pain. The intergroup effect sizes were large [Cohen’s
d = 2.72, 95 percent confidence interval, 1.94–3.44
for neck pain, and d = 2.45, 95 percent confidence
interval, 1.66–3.23 shoulder/axillary pain]. The inter-
vention group experienced greater increases in PPT
bilaterally than the control group and the intergroup
effect sizes were large. The distribution of active TrPs
in the intervention group changed significantly, while
it remained unchanged in the control group.
Comments
Recent studies showed the high prevalence of TrPs in
breast cancer survivors (14,15). This elegant trial de-
monstrated that a multimodal physical therapy
program, including aerobic training, muscle stretching
and strengthening exercises, and myofascial release
techniques, has a better outcome than usual care.
The large effect sizes show the clinical importance of
this intervention. The prevalence of active TrPs
changed significantly in the intervention group but
remained unchanged in the control group, supporting
the idea that TrPs are a common phenomenon in
breast cancer survivors if not appropriately treated.
The increase of PPT following the intervention indi-
cates the decrease in mechanical pain hypersensitivity
suggesting a generalized hypoalgesic effect of the
program besides a local effect on neck, shoulder, axil-
lary pain, and the prevalence of TrPs. Due to the
design of this trial, it is not possible to determine
which part of the program was primarily responsible
for the good clinical results. Future studies are
needed to focus on one or more components of the
program to further investigate this [CB].
REVIEWS
Soares A, Andriolo RB, Atallah ÁN, da Silva EMK:
Botulinum toxin for myofascial pain syndromes in
adults. Cochrane Database Syst Rev 4. Art. No.:
CD007533. DOI: 10.1002/14651858.CD007533.
pub2, 2012.
Summary
This Cochrane Review assessed the effectiveness and
safety of botulinum toxin in treating persons with
myofascial pain syndrome, excluding the neck and
  Dommerholt and Bron
head muscles. The researchers included randomized
controlled trials. The diagnosis of myofascial pain
had to be based on the identification of TrPs in the
taut band through palpation, a LTR, and specific pat-
terns of referred pain associated with each TrP. Four
studies were included in the review. Based on these
studies, the researchers concluded that there is incon-
clusive evidence to support the use of botulinum
toxin in the treatment of persons with myofascial
pain. They could not perform a meta-analyses due
to the heterogeneity between the studies.
Comments
Cochrane Systematic Reviews are generally con-
sidered authoritative reviews on a topic. A common
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
conclusion of systematic reviews is that there are not
enough high-quality studies available to draw mean-
ingful conclusions. As Gerwin has outlined [see
below], there are many potential pitfalls in current
studies of botulinum toxin in the treatment of myo-
fascial pain and TrPs. It is a fact that at this point
in time, there is little scientific support for the use
of botulinum toxin even though botulinum toxin
seems to have a direct effect on the excessive release
For personal use only.
of acetylcholine at motor endplates and calcitonin
gene-related peptide, which are thought to be part
of the TrP etiology and pathology [JD].
Vulfsons S, Ratmansky M, Kalichman L: Trigger
point needling: Techniques and outcome. Curr
Pain Headache Rep 16(5): 407–412, 2012.
Summary
The aim of this narrative review was to present the
latest scientific updates on TrP dry needling, other
treatment methods, efficacy, and safety studies. The
authors performed a PubMed search, using the
terms “dry needling” or “intra-muscular stimulation”
for the period from January 2000 until February 2012,
which revealed 99 papers. The authors included
recent imaging studies of TrPs, several articles about
the pathophysiology, clinical efficacy, and the possible
links between TrPs and central sensitization. The
authors suggested that TrPs are discrete secondary
peripheral neurogenic manifestations of central sen-
sitization caused by primary pathology within the
common networked spinal circuits. The paper con-
cludes with some safety issues concerning dry need-
ling. Several adverse events are reported in the
literature, including some significant events, like
acute cervical epidural hematoma and unilateral or
bilateral pneumothorax. The authors concluded that
dry needling is a safe treatment if provided by ade-
quately trained physicians or physical therapists
with attention to the relevant anatomy and with
special caution when needling in the cervical and
thoracic regions.
Comments
This is a narrative review and not a systematic review.
Although the authors identified 99 articles, only 36
references were included in this paper, which may
be due to the publication’s guidelines. The review
shows once more that additional research is needed
to establish the clinical importance of TrP dry need-
ling in the management of musculoskeletal pain.
The authors included only a few clinical trials. In
the past 10 years, much fundamental research has
been conducted to get a better understanding of the
pathophysiology of myofascial pain and TrPs.
Although the authors mentioned that TrPs are dis-
crete secondary peripheral neurogenic manifestations
of central sensitization caused by primary pathology
within the common networked spinal circuits, they
did not offer any support for this assumption. In con-
clusion, this is an interesting overview of the literature
concerning TrP needling [CB].
Gerwin R: Botulinum toxin treatment of myofascial
pain: A critical review of the literature. Curr Pain
Headache Rep 16(5):413–422, 2012.
Summary
The scientific literature of the treatment of myofascial
pain with botulinum toxin injections shows rather
mixed results. This review paper aimed to evaluate
open label, single-blinded and double-blinded
studies to determine whether they were appropriately
designed, conducted, and interpreted. After a succinct
overview of the motor and sensory mechanisms of
botulinum toxin, the author listed and reviewed mul-
tiple studies of botulinum toxin in the treatment of
myofascial pain, neck, upper and lower back pain,
whiplash, temporomandibular joint dysfunction,
tension-type headaches, occipital neuralgia, and
complex regional pain syndrome. A recent Cochrane
review was found to have inclusion criteria that were
too selective and as such limited the number of
included studies.
The author provided some study-specific criticism
for each study and summarized the common pitfalls
in more detail. He emphasized that nearly all
studies showed improvements and no studies demon-
strated a complete lack of effect. In several studies, the
researchers provided an incomplete treatment proto-
col where fairly randomly selected TrPs were treated
while other clinically relevant TrPs were excluded.
In other cases, the study protocol consisted of only
 Myofascial Pain Syndrome: Trigger Points
one injection, whereas in clinical practice botulinum
toxin injections are often repeated. Another issue
the author pointed out is that some of the studies pre-
sented with a strong placebo response against which
the botulinum toxin was evaluated. For example,
when botulinum toxin TrP injections are compared
to saline TrP injections, both will have a therapeutic
effect and minimize the robustness of the control
group. In other studies, contralateral muscles were
used as controls, although these muscles are usually
synergistic or antagonistic dependent upon the par-
ticular function, and therefore they do not constitute
a valid control measure. Although the clinical effect of
botulinum toxin is about 12 weeks, some studies used
other time periods to evaluate the effect.
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
Comments
As the author clearly indicates, this paper is not a
meta-analysis, but a critical review of common meth-
odological errors in experimental studies of the effect
of botulinum toxin injections in the management of
TrPs. Although at this point in time, there is insuffi-
cient good evidence to determine whether botulinum
toxin injections are effective or not, in the hands of
For personal use only.
skilled clinicians, botulinum toxin appears to reduce
the motor and sensory components of TrPs. Most
meta-analyses do not analyze included papers with
the same amount of detail and attention as the
author presented in this excellent paper. Many
meta-analyses conclude that better and more research
is needed. Perhaps, the inclusion criteria of meta-ana-
lyses should consider whether included studies do
meet the kind of criteria Gerwin is suggesting in
this paper. Of interest is that in at least one patient-
oriented online newsletter, this paper was used to
show that botulinum toxin injections are not indi-
cated in the treatment of myofascial pain, which
was, of course, an incorrect interpretation of the
paper [JD].
Bron C, Dommerholt J: Etiology of myofascial
trigger points. Curr Pain Headache Rep 16
(5):439–444, 2012.
Summary
In this article, the authors provided an up-to-date
review of the current thinking about the etiology of
TrPs. The authors maintained that tissue damage is
not necessary for the development of TrPs. They
argued that the most common cause of TrPs is as a
result of some kind of muscle overload, which may
include sustained low-level contractions, maximal or
submaximal concentric contractions, or eccentric
contractions. The authors briefly discussed an

alternate hypothesis by Hocking, which was pub-
lished in this journal (16).
Comments
As the authors of this article happened to be the
authors of this review column, we opted not to offer
any additional comments. May the reader provide
us with feedback [CB and JD]!
CASE REPORTS
Uludag M, Kaparov A, Sari H, Ornek NI, Gun K,
Suzen S, Akarirmak U: Osteopoikilosis associated
with fibromyalgia and active myofascial trigger
point in upper trapezius muscles. J Back Musculos-
kel Rehabil 24(4): 257–261, 2011.
Summary
This case report presents a 58-year old slightly obese
[body mass index = 29.6] housewife with a history of
neck and low back pain for 10 years. Her pain
increased over the last three months and limited her
in her daily activities. She was also suffering from
widespread musculoskeletal pain, headache, fatigue,
and sleep problems. TrPs were identified bilaterally
in the upper trapezius as exquisitely painful spots in
a taut band. Palpation elicited referred pain [not indi-
cated where the referred pain was felt], which was
recognized as familiar pain by the patient. Cervical
range of motion was slightly restricted and painful
in flexion and bilateral rotation. All other cervical
tests were negative. The lumbar interspinous spaces
were painful with palpation and range of motion of
the lower back was minimally restricted and painful
in flexion. All [18 of 18] tender points for fibromyal-
gia syndrome [FMS] were painful. All other lumbar,
pelvic, and hip tests were negative. Neurological
testing showed no abnormalities. Blood tests revealed
no abnormalities. Radiological examination showed
numerous round oval-shaped sclerotic foci in
varying size, predominantly in regions adjacent to
the hip joint and the ramus of the pubic bone.
These sclerotic foci were also found in the hands,
proximal humerus, and around the scapula bilateral.
Based on the radiological findings, osteopoikilosis
[OPK] was diagnosed. OPK is a rare condition
[prevalence is estimated at 1:50,000] which usually
remains asymptomatic throughout life. However,
15–20 percent of patients with OPK have mild bone
or joint pain. The diagnosis of FMS was based on
history, physical examination, and normal blood
tests. The diagnosis of myofascial pain caused by
TrPs in the upper trapezius was based on the findings
on musculoskeletal examination, including palpation.
  Dommerholt and Bron
Comments
This case study presents a middle-aged woman with
musculoskeletal complaints explained by a combi-
nation of three diagnoses. The objective of this case
report remains unclear, but it seems unlikely that
there is a direct correlation between OPK, FMS, and
myofascial pain, as most patients suffering from fibro-
myalgia or TrPs do not have OPK, and 80 percent of
patients with OPK remain asymptomatic throughout
life. It would be interesting if the authors had reported
the results of any treatment. They performed TrP in-
jections in the upper trapezius muscle and were able
to elicit some LTRs, but the overall outcome was
not included in the report. The case report is of
some value as it reminds clinicians that some patients
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will have rare and often undiagnosed medical diag-
noses [CB].
Westrick RB, Zylstra E, Issa T, Miller JM, Gerber
JP: Evaluation and treatment of musculoskeletal
chest wall pain in a military athlete. Intern J
Sports Phys Ther 7(3): 323–332, 2012.
Summary
For personal use only.
A 22-year-old male presented to physical therapy
with a primary complaint of left-sided anterior
chest pain. The pain gradually got worse especially
after increased physical training, including push-
ups. Resting pain was 3/10 on a numeric pain rating
scale, but increased to 7/10 following training.
Based on the history, the therapist assumed that the
pain was musculoskeletal in nature. Upon evaluation,
the pain was reproduced with palpation over the ante-
riomedial aspect of the left ribs 2–4, the left side of the
sternum, and the corresponding costochondral joint.
Muscle tightness was noted in the pectoralis minor
muscle. The patient reported minor pain with resisted
left shoulder flexion, abduction, and internal rotation.
He was initially diagnosed with costochondritis and
received stretching and range of motion exercises.
After two weeks, the resting pain had resolved, but
the chest pain returned when the patient resumed
physical exercise. At that point, he was diagnosed
with thoracic spine hypomobility and underwent
spinal and costochondral mobilizations and manipu-
lations, which did not resolve the pain.
After several weeks, dry needling was considered
and the patient received a second opinion by
another physical therapist with advanced training in
dry needling. After another assessment, dry needling
was performed targeting “the costochondral joint and
soft tissue,” which reproduced the patient’s symptoms
but did not reduce the pain. During a second session
with dry needling, the second rib costochondral
region was needled again along with “palpable
tender bands of soft tissue in the left pectoralis
muscle region.” LTRs were elicited. The symptoms
subsided quickly. The patient received further dry
needling to the left pectoralis major muscle in the
area of reported symptoms. In total, the patient had
four sessions of costochondral and muscle dry need-
ling. Following the case description, the authors
described several aspects of dry needling, the need
for proper training, and the potential adverse events.
Comments
This case report illustrates the treatment of a patient
with anterior chest wall pain following physical
activity. Dry needling appeared to be one of the
more effective treatment options. Of interest is that,
initially, the physical therapist appeared to focus on
possible joint issues. No until the “joint approach”
did not have satisfactory results, the therapist con-
sidered dry needling, although he was not trained in
the treatment of muscles overlying the chest wall.
Of further interest is that initially dry needling was
performed targeting the costochondral joint. The
paper does not describe the joint dry needling pro-
cedure in detail and it is not clear whether the
needle was actually inserted into the joint space or
capsule or whether the therapist performed some
form of periosteal needling. Periosteal needling has
been described in the literature (17,18), but there is
not much evidence of its efficacy. In the United
States, needling of joints is generally not in the
scope of physical therapy practice even in those
states where dry needling has been approved. When
the authors described the muscle dry needling tech-
niques, they did not mention that they were targeting
TrPs. Dry needling of TrPs was mentioned in the
introduction to the paper. The paper lacked a bit in
providing enough details to fully appreciate what
was being targeted during the dry needling sessions.
In summary, this is an interesting case report that
illustrates that a solid diagnostic workup and the
selection of appropriate therapeutic measures, includ-
ing dry needling, are indicated to return this patient
to full functioning without restrictions [JD].
Jarrell J: Myofascial pain in the adolescent. Curr
Opin Obstet Gynecol 22(5): 393–398, 2010.
Summary
In this paper, the author presents an adolescent
female patient with pelvic pain, who was initially
diagnosed with a ruptured endometrioma, resulting
in the removal of her right ovary and cauterization
 Myofascial Pain Syndrome: Trigger Points
of several areas of endometriosis. Three years later,
she presented to the emergency room with severe
right lower quadrant pain, inability to maintain a
job due to pain, major depression, disturbed sleep,
pain with sexual activity, sitting, standing, and
walking. A pelvic examination revealed severe pain
in the posterior introitus, but an ultrasound did
not show any abnormalities. Although she had two
negative laparoscopies, another laparoscopy was
considered.
Jarrell provided a thorough review of the current
literature on the discrepancies between the severity
of endometriosis and the severity of pain, pain defi-
nitions, nociceptive pain, somatic pain, the epide-
miology of chronic pelvic pain in children and
J Muscoskeletal Pain Downloaded from informahealthcare.com by Dr. Carel Bron on 06/15/14
adolescents, and the problems with laparoscopies. In
a section on Myofascial Pain, he described the links
between visceral disease and myofascial dysfunction,
cutaneous allodynia, and reduced pain thresholds.
He argued that documentation of signs of viscero-
somatic referral of pain may validate the illness and
symptoms of patients and further direct the treatment
approach. He advocates using an interdisciplinary
approach with physicians, nurses, physical therapists,
For personal use only.
psychologists, nutritionists, and psychiatrists.
Comments
As this is a fairly brief article, the author was only able
to highlight several important aspects of the assess-
ment of patients with enigmatic pain. There is emer-
ging literature that myofascial dysfunction may be
intricately linked to various pain states. Jarrell warns
that clinicians may rely too much on operative laparo-
scopy. Incorporating relatively simple office pro-
cedures to assess the presence of viscera-somatic
pain patterns is very important as also described in
the review of Jarrell et al.’s “Bedside testing for
chronic pelvic pain: discriminating visceral from
somatic pain” [JD].
Whisler SL, Lang DM, Armstrong M, Vickers J,
Qualls C, Feldman JS: Effects of myofascial release
and other advanced myofascial therapies on chil-
dren with cerebral palsy: six case reports. Explore
8(3): 199–205, 2012.
Summary
This is a report of the use of myofascial release tech-
niques including TrP release, myofascial movement
facilitation, and craniosacral therapy on six pro-
foundly globally developmentally disabled children
with cerebral palsy, among other diagnoses. An
experienced massage therapist provided all interven-
tions in the presence of a physician. He used a

standardized TrP release protocol on all subjects,
although the order was not necessarily the same.
Each child was treated for a total of six sessions. Care-
givers were taught how to perform the release tech-
niques and they continued the therapy for at least
18 weeks following the initial sessions. Two phys-
icians assessed the children before and at various in-
tervals after the initial treatments using the Modified
Ashworth Scale of Spasticity, but they also assessed
body symmetry, muscle tone, range of motion, teeth
grinding, ambulation, self-stimulation behaviors,
alertness, cooperation, and fatigue.
The authors briefly described each subject. Results
ranged from an improved ability to lay in supine, to
changes in muscle tone, a reduction of self-stimu-
latory behaviors, teeth grinding, and in one subject,
a decrease in choreoathetoid movements. Another
subject, who also received simultaneous colonic irri-
gation hydrotherapy, was able to have bowel move-
ments without external stimuli. Caregivers reported
significant changes in most of the other parameters.
The authors concluded that TrP release can be ben-
eficial in decreasing muscle spasticity and in treating
certain behavioral problems in children with cerebral
palsy.
Comments
As the authors acknowledged, this is a rare report on
the effect of TrP release on spasticity and other par-
ameters in children with cerebral palsy. This paper
is kind of in-between a scientific study and a case
report. The authors plan to conduct a better study
in the future with a larger sample size and more con-
trolled outcome measures. Especially the reliance on
caregivers’ reports is likely to be quite unreliable.
The children in this study had varied other diagnoses
in addition to cerebral palsy. A more homogenous
population will make it easier to apply standardized
treatments and outcome measures. Treatment of
spasticity with TrP therapy is not common particu-
larly with children, and the authors are complemen-
ted with adding this important case report to the
literature [JD].
Declaration of interest: The authors reports no
conflict of interest.
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For personal use only.
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