Treatment of myofascial trigger points in common shoulder disorders by physical therapy: a randomized controlled trial [ISRCTN75722066]

Carel Bron, Michel Wensing, Jo Lm Franssen, Rob Ab Oostendorp, Carel Bron, Michel Wensing, Jo Lm Franssen, Rob Ab Oostendorp

Abstract

Background: Shoulder disorders are a common health problem in western societies. Several treatment protocols have been developed for the clinical management of persons with shoulder pain. However available evidence does not support any protocol as being superior over others. Systematic reviews provide some evidence that certain physical therapy interventions (i.e. supervised exercises and mobilisation) are effective in particular shoulder disorders (i.e. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis), but there is an ongoing need for high quality trials of physical therapy interventions. Usually, physical therapy consists of active exercises intended to strengthen the shoulder muscles as stabilizers of the glenohumeral joint or perform mobilisations to improve restricted mobility of the glenohumeral or adjacent joints (shoulder girdle). It is generally accepted that a-traumatic shoulder problems are the result of impingement of the subacromial structures, such as the bursa or rotator cuff tendons. Myofascial trigger points (MTrPs) in shoulder muscles may also lead to a complex of symptoms that are often seen in patients diagnosed with subacromial impingement or rotator cuff tendinopathy. Little is known about the treatment of MTrPs in patients with shoulder disorders.The primary aim of this study is to investigate whether physical therapy modalities to inactivate MTrPs can reduce symptoms and improve shoulder function in daily activities in a population of chronic a-traumatic shoulder patients when compared to a wait-and-see strategy. In addition we investigate the recurrence rate during a one-year-follow-up period.

Methods/design: This paper presents the design for a randomized controlled trial to be conducted between September 2007 - September 2008, evaluating the effectiveness of a physical therapy treatment for non-traumatic shoulder complaints. One hundred subjects are included in this study. All subjects have unilateral shoulder pain for at least six months and are referred to a physical therapy practice specialized in musculoskeletal disorders of the neck-, shoulder-, and arm. After the initial assessment patients are randomly assigned to either an intervention group or a control-group (wait and see). The primary outcome measure is the overall score of the Dutch language version of the DASH (Disabilities of Arm, Shoulder and Hand) questionnaire.

Discussion: Since there is only little evidence for the efficacy of physical therapy interventions in certain shoulder disorders, there is a need for further research. We found only a few studies examining the efficacy of MTrP therapy for shoulder disorders. Therefore we will perform a randomised clinical trial of the effect of physical therapy interventions aimed to inactivate MTrPs, on pain and impairment in shoulder function in a population of chronic a-traumatic shoulder patients. We opted for an intervention strategy that best reflects daily practice. Manual high velocity thrust techniques and dry-needling are excluded. Because in most physical therapy interventions, blinding of the patient and the therapist is not possible, we will perform a randomised, controlled and observer-blinded study.

Trial registration: This randomized clinical trial is registered at current controlled trials ISRCTN75722066.

Figures

Figure 1
Figure 1
recruitment and experimental plan.

References

    1. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33:73–81. doi: 10.1080/03009740310004667.
    1. Bongers PM. The cost of shoulder pain at work. BMJ. 2001;322:64–65. doi: 10.1136/bmj.322.7278.64.
    1. Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of shoulder pain in the community: the influence of case definition. Ann Rheum Dis. 1997;56:308–312.
    1. Bergman GJD. Manipulative therapy for shoulder complaints in general practice. University of Groningen, The Netherlands; 2005.
    1. van der Windt DA, Koes BW, Boeke AJ, Deville W, de Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract. 1996;46:519–523.
    1. HSJ P, van GHWV, JSAG S. Klachten van het bewegingsapparaat in de Nederlandse bevolking. Prevalenties, consequenties en risicogroepen. Bilthoven, CBS; 2000.
    1. Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis and management in primary care. BMJ. 2005;331:1124–1128. doi: 10.1136/bmj.331.7525.1124.
    1. Winters JC, Jorritsma W, Groenier KH, Sobel JS, Jong BM, Arendzen HJ. Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study comparing physiotherapy, manipulation, and corticosteroid injection. BMJ. 1999;318:1395–1396.
    1. Winters JC, Jongh AC, van der Windt DAWM, et al. NHG standaard schouderklachten [Guidelines for Shoulder Complaints of the Dutch College of General Practioners (version 1999). Huisarts Wet. 1999;42:222–231.
    1. Clinical Guideline of Shoulder pain of the American Academy of Orthopaedic Surgeons. 2001.
    1. Shoulder Guideline of the New Zealand Guidelines Group. 2004.
    1. Karjalainen K, Malmivaara A, van TM, Roine R, Jauhiainen M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2001;26:174–181. doi: 10.1097/00007632-200101150-00012.
    1. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:CD004258.
    1. Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain. Cochrane Database Syst Rev. 2000:CD001156.
    1. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005:CD005319.
    1. Ejnisman B, Andreoli CV, Soares BG, Fallopa F, Peccin MS, Abdalla RJ, Cohen M. Interventions for tears of the rotator cuff in adults. Cochrane Database Syst Rev. 2004:CD002758.
    1. Simons DG, Travell JG, Simons LS, Travell JG. Travell & Simons' myofascial pain and dysfunction The trigger point manual. 2nd. Baltimore, Williams & Wilkins; 1999.
    1. Baldry P. Acupuncture, Trigger Points and Musculoskeletal Pain. third. Churchill Livingstone; 2004.
    1. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004;8:468–475. doi: 10.1007/s11916-004-0069-x.
    1. Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. 1998;79:863–872. doi: 10.1016/S0003-9993(98)90371-9.
    1. Mense S, Simons DG, Hoheisel U, Quenzer B. Lesions of rat skeletal muscle after local block of acetylcholinesterase and neuromuscular stimulation. J Appl Physiol. 2003;94:2494–2501. doi: 10.1063/1.1582380.
    1. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005;99:1977–1984. doi: 10.1152/japplphysiol.00419.2005.
    1. Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofacial trigger points. Am J Phys Med Rehabil. 2002;81:212–222. doi: 10.1097/00002060-200203000-00010.
    1. Dommerholt J, Bron C, Franssen JLM. Myofascial trigger points; an evidence-based review. J Manual Manipulative Therapy. 2006;14:203–221.
    1. Wolfe F, Simons DG, Fricton J, Bennett RM, Goldenberg DL, Gerwin R, Hathaway D, McCain GA, Russell IJ, Sanders HO, . The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol. 1992;19:944–951.
    1. Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69:65–73. doi: 10.1016/S0304-3959(96)03248-4.
    1. Bron C, Wensing M, Franssen JLM, RAB O. Interobserver Reliability of Palpation of Myofascial Trigger Points in Shoulder Muscles. Journal Manual Manipulative Therapy. 2007;15:in press.
    1. Ingber RS. Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments. Arch Phys Med Rehabil. 2000;81:679–682. doi: 10.1016/S0003-9993(00)90053-4.
    1. Weed ND. When shoulder pain isn't bursitis. The myofascial pain syndrome. Postgrad Med. 1983;74:97–2, 104.
    1. Grosshandler SL, Stratas NE, Toomey TC, Gray WF. Chronic neck and shoulder pain. Focusing on myofascial origins. Postgrad Med. 1985;77:149–8.
    1. Bron C, Franssen JLM, de Valk BGM. Een posttraumatische schouderklacht zonder aanwijsbaar letsel. Ned Tijdschrift v Fysiotherapie. 2001. pp. 97–102.
    1. JG T, DG S. Myofascial Pain and Dysfunction The Trigger Point Manual The lower extremities. first. II. Baltimore, Lippincott, Williams and Wilkins; 1999.
    1. Neblett R, Gatchel RJ, Mayer TG. A clinical guide to surface-EMG-assisted stretching as an adjunct to chronic musculoskeletal pain rehabilitation. Appl Psychophysiol Biofeedback. 2003;28:147–160. doi: 10.1023/A:1023814709858.
    1. Neblett R, Mayer TG, Gatchel RJ. Theory and rationale for surface EMG-assisted stretching as an adjunct to chronic musculoskeletal pain rehabilitation. Appl Psychophysiol Biofeedback. 2003;28:139–146. doi: 10.1023/A:1023862625787.
    1. Franssen JLM. In: Handboek oppervlakte-elektromyografie. First. Franssen JLM, editor. Utrecht, De Tijdstroom; 1995.
    1. Veiersted KB, Westgaard RH, Andersen P. Pattern of muscle activity during stereotyped work and its relation to muscle pain. Int Arch Occup Environ Health. 1990;62:31–41. doi: 10.1007/BF00397846.
    1. Hagg GM. Static Work Loads and Occupational Myalgia - A New Explanational Model. In: Anderson PA, Hobart DJ and Danoff JV, editor. Electromyographical kinesiology. Amsterdam - New York - Oxford, Exerpta Medica; 1991. pp. 141–144.
    1. Hagg GM, Luttmann A, Jager M. Methodologies for evaluating electromyographic field data in ergonomics. J Electromyogr Kinesiol. 2000;10:301–312. doi: 10.1016/S1050-6411(00)00022-5.
    1. Roman-Liu D, Tokarski T, Wojcik K. Quantitative assessment of upper limb muscle fatigue depending on the conditions of repetitive task load. J Electromyogr Kinesiol. 2004;14:671–682. doi: 10.1016/j.jelekin.2004.04.002.
    1. Szeto GP, Straker LM, O'Sullivan PB. EMG median frequency changes in the neck-shoulder stabilizers of symptomatic office workers when challenged by different physical stressors. J Electromyogr Kinesiol. 2005;15:544–555. doi: 10.1016/j.jelekin.2005.06.004.
    1. Peper E, al The Integration of electromyography (SEMG) at the workstation: assessment, treatment, and prevention of repetitive strain injury (RSI). Appl Psychophysiol Biofeedback. 2003;28:167–182. doi: 10.1023/A:1023818810766.
    1. Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473–483. doi: 10.1097/00005650-199206000-00002.
    1. Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain. 1997;13:163–170. doi: 10.1097/00002508-199706000-00011.
    1. Solway S, Beaton DE, McConnell S, Bombardies C. The DASH Outcome Measure User's Manual. Second. Toronto, Ontario, Institute for Work & Health; 2002.
    1. Turchin DC, Beaton DE, Richards RR. Validity of observer-based aggregate scoring systems as descriptors of elbow pain, function, and disability. J Bone Joint Surg Am. 1998;80:154–162.
    1. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–146.
    1. Beaton DE, Davies AM, Hudak P, McConnell S. The DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure: What do we know about it now? British Journal of Hand Therapy. 2001;6:109–118.
    1. Bot SD, Terwee CB, van der Windt DA, Bouter LM, Dekker J, de Vet HC. Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Ann Rheum Dis. 2004;63:335–341. doi: 10.1136/ard.2003.007724.
    1. Clarkson HM. Joint Motion and Function Assessment A research-based practical Guide. 1st. Philadelphia;Baltimore, Lippincott, Williams & Wilkins; 2005.
    1. W, Heemskerk MA, Terwee CB, Jans MP, Deville W, van Schaardenburg DJ, Scholten RJ, Bouter LM. Inter-observer reproducibility of measurements of range of motion in patients with shoulder pain using a digital inclinometer. BMC Musculoskelet Disord. 2004;5:18. doi: 10.1186/1471-2474-5-18.
    1. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11. doi: 10.1186/1471-2474-4-11.
    1. Altman DG. Practical statistics for medical research. first. Chapman & Hall; 1991.
    1. Thomas E, van der Windt DA, Hay EM, Smidt N, Dziedzic K, Bouter LM, Croft PR. Two pragmatic trials of treatment for shoulder disorders in primary care: generalisability, course, and prognostic indicators. Ann Rheum Dis. 2005;64:1056–1061. doi: 10.1136/ard.2004.029959.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj