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2006 - Vol. 14, No. 4

Free Content:

Guest Editorial Neuromusculoskeletal Medicine-Dawning of A New Day
Online-Only Article Trigger Point Dry Needling
Online-Only Article Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report
Online-Only Article Myofascial Trigger Points and Myofascial Pain Syndrome: A Critical Review of Recent Literature (With an Introduction by the Editor-in-Chief)
ABSTRACTS Abstracts: AAOMPT Conference 2006 (Addendum)
BOOK, CD, AND TAPE REVIEWS Book, CD and Tape Reviews
AUTHOR INDEX 2006 2006 Index of all authors contributing to Volume 14 of the Journal of Manual and Manipulative Therapy
SUBJECT INDEX 2006 Index of all subjects discussed in the articles published in Volume 14 of the Journal of Manual and Manipulative Therapy
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Myofascial Trigger Points: An Evidence-Informed Review

Jan Dommerholt, PT, MPS, FAAPM, Carel Bron, PT, Jo Franssen, PT

Abstract: This article provides a best evidence-informed review of the current scientific understanding of myofascial trigger points with regard to their etiology, pathophysiology, and clinical implications. Evidence-informed manual therapy integrates the best available scientific evidence with individual clinicians’ judgments, expertise, and clinical decision-making. After a brief historical review, the clinical aspects of myofascial trigger points, the interrater reliability for identifying myofascial trigger points, and several characteristic features are discussed, including the taut band, local twitch response, and referred pain patterns. The etiology of myofascial trigger points is discussed with a detailed and comprehensive review of the most common mechanisms, including low-level muscle contractions, uneven intramuscular pressure distribution, direct trauma, unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle, and maximal or sub-maximal concentric contractions. Many current scientific studies are included and provide support for considering myofascial trigger points in the clinical decision-making process. The article concludes with a summary of frequently encountered precipitating and perpetuating mechanical, nutritional, metabolic, and psychological factors relevant for physical therapy practice. Current scientific evidence strongly supports that awareness and working knowledge of muscle dysfunction and in particular myofascial trigger points should be incorporated into manual physical therapy practice consistent with the guidelines for clinical practice developed by the International Federation of Orthopaedic Manipulative Therapists. While there are still many unanswered questions in explaining the etiology of myofascial trigger points, this article provides manual therapists with an up-to-date evidence-informed review of the current scientific knowledge.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 4 (2006), 203-221

Contributions of Myofascial Trigger Points to Chronic Tension Type Headache

Cesar Fernandez-de-las-Penas, PT, DO, Lars Arendt-Nielsen, DMSc, PhD, David G. Simons, MD

Abstract: Tension-type headache (TTH) is characterized by bilateral, pressing or tightening pain; pressure or band-like tightness; and/or increased tenderness on palpation of neck and shoulder muscles. These features resemble the descriptions of referred pain originating in myofascial trigger points (TrPs). The present paper deals with the scientific evidence supporting the hypothesis that referred pain elicited by TrPs contributes to pain perception in TTH. Animal and human studies clearly show the convergence of cervical and trigeminal afferents in the trigeminal nerve nucleus caudalis, constituting the anatomical basis for the referred head pain from neck and shoulder muscle TrPs. Referred pain patterns have been described from different TrPs in several head and neck muscles that have the potential to refer to the head. Several human pain models have confirmed some of these clinical pain patterns by injecting algogenic substances into the muscles. Recent studies have demonstrated that chronic TTH was associated with active TrPs in the suboccipital, upper trapezius, sternocleidomastoid, temporalis, and superior oblique muscles. In addition, chronic TTH patients with active TrPs have greater headache intensity and frequency than those with latent TrPs. Active TrPs have also been found on the symptomatic, but not in the contra-lateral side in unilateral migraine patients. Higher levels of algogenic substances have been found in active TrPs as compared to latent TrPs and tender points, which may lead to increased afferent bombardment into the nucleus caudalis. This would result in temporal and spatial summation of neuron signals and may cause central sensitization in chronic TTH. Pain at rest falls in this category if it results from TrP activity. It seems that the pain profile of TTH can include referred pain from TrPs in the posterior cervical, head (including extra-ocular muscles), and shoulder muscles. Further research could delineate more information on the relation between TrPs on TTH.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 4 (2006), 222-231

Myofascial Trigger points: Translating Molecular Theory into Manual Therapy

John M. McPartland, DO, MS, David G. Simons, MD

Abstract: Theories regarding the molecular pathophysiology of myofascial trigger points (MFTrPs) have undergone fundamental revisions in recent years. New research suggests that MFTrPs are evoked by the abnormal depolarization of motor endplates. The motor endplate transduces electrical potential into muscle contraction. This review article expands the proposed etiology to include presynaptic, synaptic, and postsynaptic mechanisms, such as excessive release of acetycholine (ACh), defects of acetylcholinesterase, and upregulation of nicotinic ACh receptors, respectively. Dysfunctional motor endplates and sustained muscular contraction give rise to a localized “ATP energy crisis” associated with sensory and autonomic reflex arcs that is sustained by central sensitization. This working hypothesis has given rise to several new approaches in the treatment of MFTrPs.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 4 (2006), 232-239

Trigger Point Dry Needling

Jan Dommerholt, Orlando Mayoral del Moral, Christian Grobli

Abstract: Trigger point dry needling is a treatment technique used by physical therapists around the world. In the United States, trigger point dry needling has been approved as within the scope of physical therapy practice in a growing number of states. There are several dry needling techniques, based on different models, including the radiculopathy model and the trigger point model, which are discussed here in detail. Special attention is paid to the clinical evidence for trigger point dry needling and the underlying mechanisms. Comparisons with injection therapy and acupuncture are reviewed. Trigger point dry needling is a relatively new technique used in combination with other physical therapy interventions.
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Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Tamer S. Issa PT, BSc, DPT, Peter A. Huijbregts PT, DPT, OCS, FAAOMPT, FCAMT

Abstract: Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.
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Myofascial Trigger Points and Myofascial Pain Syndrome: A Critical Review of Recent Literature (With an Introduction by the Editor-in-Chief)

David G. Simons, MD, Jan Dommerholt, PT, MPS, FAAPM

Abstract: This review of relevant literature provides the readers with the unique opportunity to more closely review many of the studies referenced in the various articles that make up this issue of the Journal. It also provides readers perhaps not familiar with this area of orthopaedic manual therapy with a bibliography for further study and allows for critical evaluation of the state-of-the art of research in this area and claims made as to the evidence base. Some of the articles reviewed here discuss interventions that may not necessarily be included in the scope of practice of all readers. At times, interventions such as acupuncture, magnetic field stimulation, dry needling, and infiltrations will seem far removed from the familiar terrain of orthopaedic manual therapy. However, it benefits all of our patients if we are familiar with the interventions available and, perhaps more importantly, the –at times limited-- research basis supporting claims for their efficacy.
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ABSTRACTS: AAOMPT Conference, 2006 (Addendum)

The abstract below was presented at the 12th annual meeting of the American Academy of Orthopaedic Manual Physical Therapists held in Charlotte, North Carolina from October 20-22, 2006 but not included with the other abstracts published in volume 14, number 3 of the Journal. Abstracts are reviewed by an AAOMPT committee to establish suitability for presentation at the conference. However, inclusion of this abstract in this issue of the Journal does not constitute a peer-reviewed journal publication. The publication of abstracts alerts readers to research that is presently being conducted. It is hoped that the research presented here in brief will eventually be submitted as full-length manuscripts for review and potential publication.
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