Chiropractic Management of Myofascial Trigger Points
and Myofascial Pain Syndrome: A Systematic
Review of the Literature

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   J Manipulative Physiol Ther. 2009 (Jan); 32 (1): 14–24 ~ FULL TEXT

OPEN ACCESS

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Howard Vernon, DC, PhD, and Michael Schneider, DC

Canadian Memorial Chiropractic College,
Ontario, Canada.
hvernon@cmcc.ca

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OBJECTIVES:   Myofascial pain syndrome (MPS) and myofascial trigger points (MTrPs) are important aspects of musculoskeletal medicine, including chiropractic. The purpose of this study was to review the most commonly used treatment procedures in chiropractic for MPS and MTrPs.

METHODS:   The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and databases for systematic reviews and clinical guidelines were searched. Separate searches were conducted for (1) manual palpation and algometry, (2) chiropractic and other manual therapies, and (3) other conservative and complementary/alternative therapies. Studies were screened for relevance and rated using the Oxford Scale and Scottish Intercollegiate Guidelines Network rating system.

RESULTS:   A total of 112 articles were identified. Review of these articles resulted in the following recommendations regarding treatment: Moderately strong evidence supports manipulation and ischemic pressure for immediate pain relief at MTrPs, but only limited evidence exists for long-term pain relief at MTrPs. Evidence supports laser therapy (strong), transcutaneous electrical nerve stimulation, acupuncture, and magnet therapy (all moderate) for MTrPs and MPS, although the duration of relief varies among therapies. Limited evidence supports electrical muscle stimulation, high-voltage galvanic stimulation, interferential current, and frequency modulated neural stimulation in the treatment of MTrPs and MPS. Evidence is weak for ultrasound therapy.

CONCLUSIONS:   Manual-type therapies and some physiologic therapeutic modalities have acceptable evidentiary support in the treatment of MPS and TrPs.

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From the Full-Text Article:

Introduction

Ever since the seminal work of Travell and Rinzler [1] in 1952, the role of myofascial trigger points (TrPs) in myofascial pain syndrome (MPS) has become an accepted part of musculoskeletal clinical practice. Along with Simons, [2] Travell first identified the importance of myofascial pain and its localization in what they termed trigger points, providing the first classification of diagnostic criteria for TrPs. They also provided detailed maps of the pain referral patterns from TrPs in all the muscles of the body. Myofascial pain syndrome is currently thought to be the leading diagnosis among pain management specialists [3] and the leading diagnosis in pain patients reporting to general practitioners. [4]

Interest in myofascial tenderness extends throughout the history of chiropractic. It might be said that local paraspinal tenderness, as part of the manifestations of the “subluxation,” was a central feature of chiropractic thinking from its inception. Arguably, the work of Ray Nimmo [5–7] represents the earliest and perhaps still most established thinking on this topic among chiropractors. Cohen and Gibbons [8] describe his work as “a conceptual leap from moving bones to working with muscles that move bones.” Schneider [9, 10] has provided a collection and review of all of Nimmo's works. Nimmo's explanations in the 1950s of the pathophysiology of TrPs are still regarded as accurate and highly sophisticated.

Other chiropractic authors who have written on this topic include Schneider, [9–12] Perle, [13, 14] Hains, [15, 16] and Hammer, [17] whose seminal textbook is now in its third printing. There are also numerous case reports and technical reports relating to various soft tissue techniques in chiropractic. In the field of MPS, chiropractic is generally regarded as one of the complementary and alternative medical (CAM) therapies. The CAM therapies are quite commonly used in the treatment of myofascial pain and TrPs, [18] and there is considerable overlap between chiropractic approaches and CAM therapies in this field.

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Conclusion

The published evidence for the treatment of MPS and TrPs by common chiropractic treatments has been reviewed. Although publications ranging from systematic reviews and clinical trials to clinical reviews were included in the review, the evidence ratings were developed only on the basis of the clinical trial evidence. Manual-type therapies and some physiologic therapeutic modalities have acceptable evidentiary support in the treatment of MPS and TrPs (Table 10).

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Practical Applications

• There is evidence that manual therapies are useful in short-term relief of TrP pain.
  

• There is evidence that laser and acupuncture are useful in the short- and long-term relief of MPS.

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References

1. Travell J, Rinzler S.
   The myofascial genesis of pain.
   Postgrad Med. 1952;   11:   425–434
   

2. Travell J, Simons DG.
   Myofascial pain and dysfunction: the trigger point manual.
   Baltimore (Md): Williams and Wilkens; 1983
   

3. Harden RN, Bruehl SP, Gass S, Niemiec C, Barbick B.
   Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers.
   Clin J Pain. 2000;   16:   64–72
   

4. Skootsky SA, Jaeger B, Oye RK.
   Prevalence of myofascial pain in general internal medicine.
   West J Med. 1989;   151:   157–160
   

5. Nimmo RL.
   The development of chiropractic through the perspective of Dr. Raymond Nimmo [videorecording].
   Pasadena (Tex): Texas Chiropractic College; 1984
   

6. Nimmo RL.
   The receptor-tonus method.
   Pasedena (Tex): Texas Chiropractic College; 1992
   

7. Nimmo RL.
   The receptor-tonus method: directory 1962.
   Self-published
   

8. Cohen JH, Gibbons RW,
   Raymond L. Nimmo and the evolution of trigger point therapy, 1929-1986.
   J Manipulative Physiol Ther. 1998;   21:   167–172
   

9. Schneider M.
   Receptor-tonus technique assessment.
   Chiropr Tech. 1994;   6:   156–159
   

10. Schneider M.
    The collected writings of Nimmo and Vannerson: pioneers of chiropractic trigger point therapy.
    Pittsburgh (Pa): Michael Schneider; 2001
    

11. Schneider MJ.
    Snapping hip syndrome in a marathon runner: treatment by manual trigger point therapy — a case study.
    Chiropr Sports Med. 1990;   4:   54–58
    

12. Schneider M.
    Tender points/fibromyalgia vs trigger points/myofascial pain syndrome: a need for clarity in terminology and differential diagnosis.
    J Manipulative Physiol Ther. 1995;   18:   398–406
    

13. Perle SM.
    Understanding trigger points: key to relieving myotogenous pain.
    Chiropr J. 1989;   3:   17
    

14. Perle SM.
    Myofascial trigger points.
    Chiropr Sports Med. 1995;   9:   106–108
    

15. Hains G.
    Locating and Treating Low Back Pain of Myofascial Origin
    by Ischemic Compression
    J Can Chiropr Assoc 2002 (Dec); 46 (4): 257–264

16. Hains G.
    Chiropractic Management of Shoulder Pain and Dysfunction
    of Myofascial Origin Using Ischemic Compression Techniques
    J Can Chiropr Assoc. 2002 (Sep); 46 (3): 192–200

17. Hammer W.
    Functional soft tissue examination & treatment by manual methods. 3rd ed..
    Sudbury (Mass): Jones & Bartlett; 2007
    

18. Harris RE, Clauw DJ.
    The use of complementary medical therapies in the management of myofascial pain disorders.
    Curr Pain Headache Rep. 2002;   6:   370–374

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