Journal of Bodywork & Movement Therapies (2011) 15, 348e354

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

MYOFASCIAL PAIN

Immediate effect of electric point stimulation

(TENS) in treating latent upper trapezius trigger
points: A double blind randomised
placebo-controlled trial
Hugh Gemmell, DC, BA, MSc, EdD*, Axel Hilland

Anglo-European College of Chiropractic, 13e15 Parkwood Road, Bournemouth, BH5 2DF, UK

Received 30 October 2009; received in revised form 1 April 2010; accepted 7 April 2010

KEYWORDS Summary Objective: The purpose of this study was to investigate the immediate effect of
Myofascial pain; electric point stimulation in treating latent upper trapezius trigger points compared to
Trigger point; placebo.
Manual therapy; Design: Double blind randomised placebo-controlled trial.
Upper trapezius; Setting: Anglo-European College of Chiropractic.
TENS Participants: Sixty participants with latent upper trapezius trigger points.
Interventions: Electric point stimulator type of TENS, or detuned (inactive) electric point
stimulator type of TENS.
Main outcome measures: The three outcome measures were pressure pain threshold at the
trigger point, a numerical rating scale for pain elicited over the trigger point, and lateral
cervical flexion to the side opposite the trigger point.
Results: On the outcome of pressure pain threshold the electric point stimulator group had
a mean change of 0.49 (0.99) kg/cm2, while the placebo group had a mean change of 0.45
(0.98) kg/cm2 (t Z 0.16, df Z 58, p Z 0.88). For change in pain over the trigger point, the
electric point stimulator group had a mean decrease of 0.93 (0.87) points, while the placebo
group had a mean decrease of 0.23 (0.97) points (t Z 0.70, df Z 58, p Z 0.005). On the
outcome of change in lateral cervical flexion the electric point stimulator group had a mean
increase of 2.87 (4.55) degrees, while the placebo group had a mean increase of 1.99 (2.49)
degrees (t Z 0.92, df Z 58, p Z 0.36).

* Corresponding author. Tel.: þ44 1202 436268; fax: þ44 1202 436312.
E-mail address: hgemmell@aecc.ac.uk (H. Gemmell).

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2010.04.003
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points
Conclusion: Electric point stimulator type of TENS is superior to placebo only in reduction of
pain for treating latent upper trapezius trigger points.
ª 2010 Elsevier Ltd. All rights reserved.
Background
A trigger point (TrP) is defined as a hypersensitive spot in
a skeletal muscle associated with a taut band. The spot is
painful on compression and refers pain in a characteristic
pattern for each muscle. Referred tenderness, motor
dysfunction and autonomic symptoms may also occur
(Simons et al., 1999; Hong, 1994; Gerwin, 1995; Gerwin
et al., 1997). Trigger points occur anywhere in the body;
however, some muscle groups more commonly contain
TrPs, especially those involved in maintaining posture
(Rickards, 2006).
Trigger points are activated directly by muscle overload
(acute or chronic), trauma, prolonged muscle contraction,
and/or nerve compression (Simons et al., 1999; Huguenin,
2004). Furthermore TrPs may be activated indirectly by
other existing TrPs, visceral disease, joint dysfunction and
emotional distress (Simons et al., 1999; Huguenin, 2004).
Two main types of TrPs are described: active and latent
(Simons et al., 1999). Active TrPs reproduce the patient’s
usual pain. Latent TrPs produce the characteristic effects
of an active TrP, including referred pain, increased muscle
tension and shortening, but they do not produce sponta-
neous pain (Simons et al., 1999; Dommerholt et al., 2006).
It is claimed that TrPs and the attendant myofascial pain
syndrome is the most common pain disorder of muscle
origin seen in clinical practice (Audette et al., 2004). The
incidence in the general population varies between 30 and
85%, is more common in women, and pain in the majority of
cases is localised to the head, neck and shoulder region
(Han and Harrison, 1997; Rickards, 2006). The highest
incidence appears to be in patients between 30 and 40
years of age (Cooper et al., 1986; Hou et al., 2002). Latent
TrPs are more common than active TrPs (Mense and Simons,
2001; Gerwin, 1995; Drewes and Jennum, 1995; Tough
et al., 2007).
Several theories have been proposed to explain the
pathophysiology of TrPs. The integrated hypothesis is now
generally accepted as the best explanation for develop-
ment of TrPs (Simons, 2002). In this theory a local energy
crisis develops due to dysfunctional motor endplates with
release of acetylcholine (ACh) under resting conditions, and
development of contraction knots due to sustained
contraction of sarcomeres. Sustained contraction of muscle
fibres results in compression of local capillaries reducing
nutrient and oxygen supplies leading to a local energy
crisis. This, in turn, results in the release of sensitising
chemicals that interact with autonomic and sensory nerves
in the area contributing to excessive ACh release, leading
to a self-sustaining cycle (Rickards, 2006; Hanten et al.,
2000; Simons, 2002).
Transcutaneous electrical nerve stimulation (TENS) is
defined as the application of electrical stimulation to the
skin for pain control. It is non-invasive, inexpensive, safe,
and easy to use (Sluka and Walsh, 2003; Rushton, 2002).
349
Electricity has been used for thousands of years for pain
relief, with the first written account given by Aristotle
(Kane and Taub, 1975; Howe et al., 2008). However,
a theoretical foundation for electroanalgesia was only
established in 1965 through the publication of the gate
control theory (Melzack and Wall, 1965). The theory
proposed that opening or closing of the “gate” existing in
the substantia gelatinosa of the dorsal horn is dependent on
the relative activity in the large diameter fibres (A-beta)
and small diameter fibres (A-delta and C), with activity in
the large diameter fibres tending to close the “gate”, and
activity in the small diameter fibres tending to open it
(Baldry, 2005a). This gate could effectively be closed by
a variety of other types of stimulation, which activate the
large diameter afferent fibres such as cold, heat, and
electrical currents (Howe et al., 2008).
TENS has been shown to be an effective treatment
option in relieving pain caused by a number of different
disorders (Baldry, 2005b). However TENS is not described as
a specific TrP modality by Simons et al. (1999), and its
effectiveness on TrP pain has been questioned (Baldry,
2005b). Various studies have investigated the relative
effectiveness of traditional TENS on TrP pain (Graff-Radford
et al., 1989; Hou et al., 2002; Hsueh et al., 1997). However,
we were unable to find any published studies that have
investigated the effect of electric point stimulation type of
TENS on TrPs.
Therefore the purpose of this study was to investigate
the immediate effect of electric point stimulation in
treating latent upper trapezius TrPs compared to placebo
based on the outcomes of PPT, Numerical Rating Scale
(NRS) score and lateral cervical flexion.
Methods
Overview
The study was a double blind randomised placebo-
controlled trial approved by the Anglo-European College of
Chiropractic (AECC) Student Projects Panel. All participants
signed a consent form before participating in the study. The
study was conducted in a seminar room at the AECC over 6
weeks during September and October 2008. Follow up
occurred 5 min after treatment.
Participants
Volunteers (N Z 78) were recruited from students, faculty
and staff at the AECC, Bournemouth. This was done using
posters and email announcements. Sixty volunteers met the
eligibility requirements and were enrolled in the study.
Inclusion criteria for this study were: male or female
between 18 and 60 years of age, asymptomatic, a latent TrP
in the upper fibres of the trapezius muscle, pain of at least
350
4 on a 0e10 numerical rating scale with firm compression on
the latent TrP. For the purpose of this study a latent TrP
was defined as a hypersensitive spot in a taut band that
referred pain in a pattern typical for the upper trapezius
muscle, but was not causing the participant any pain
(Simons et al., 1999). Gerwin et al. (1997) suggest that the
minimum criteria required to distinguish a TrP from any
other tender area in a muscle are a taut band and tender
point in that taut band.
Participants were excluded if they had any of the
following:
1. head, neck or upper back pain
2. a pacemaker
3. epilepsy
4. possibility of pregnancy
5. diffuse generalised musculoskeletal pain.
Interventions
Electric point stimulator
We used a handheld electric point stimulator designed to
locate and treat TrPs with a pulsating TENS current. The
difference between electric point stimulation and standard
TENS is the electric current is delivered through a metal
probe on the hand held device compared to electrodes
attached to the skin. Purportedly the electric skin resistance
of the TrP is lower than its surrounding area, and the
instrument is able to detect this change (Sola and Williams,
1956; Sola et al., 1955). When the metal probe touches an
area of lowered resistance a speaker in the device emits
a sound and a small green light flashes. The pitch of the sound
rises with lowering of the skin resistance to enable precise
location of the point to be treated. When the highest pitch is
reached the button on the top of the instrument is pressed to
deliver stimulation into the TrP. Hand contact with the
indifferent hand has to be made with the participant’s skin
for the electric current to flow to the TrP. A pulsating current
of 8e10 Hz is emitted through the probe, and the intensity of
the current may be adjusted from 0 to 45 mA. A 9-V battery
powers the electric point stimulator.
Treatment was delivered to the seated participant by
placing the tip of the stimulator on the marked TrP.
Sensitivity was set low to detect areas of lowered skin
resistance over the TrP. After detecting the lowest electric
skin resistance point over the TrP, the stimulator was
activated and held with a constant pressure for 3 min. The
tip of the stimulator is spring-loaded to enable the same
pressure to be applied by increasing pressure until the
barrier of the spring is reached. Intensity of stimulation was
set to participant tolerance, and at a minimum the subject
felt a pulsating tingling sensation that was not unpleasant.
The stimulation was not strong enough to cause muscle
contraction. While there is no published research on the
hand held electric point stimulator, numerous websites tout
its ability to detect and treat acupuncture points and TrPs,
and the principal author’s clinical observation is that the
point stimulator may be useful in treating TrPs. However,
a recent study suggests that acupuncture points do not
show any changes in electrical skin resistance that are
consistent or stable over time (Kramer et al., 2009).
H. Gemmell, A. Hilland
Placebo
The same device was used for the placebo group, but with
sensitivity set high so noise and light would be the same as
for the active group. The intensity was set to zero (inac-
tive), and no contact with the indifferent hand was made
with the seated participant’s skin. This was to ensure that
no current was applied to the TrP. Light pressure with the
device (less than spring barrier) was held over the marked
TrP for 3 min. This very light pressure was used to control
for a possible treatment effect of firmer pressure to the
TrP. Therefore, while both active and placebo interventions
involved pressure over the TrP, only the active treatment
involved application of an electrical current.
Objectives
The specific objectives were to determine if there was
a statistically significant difference in pressure pain
threshold, in pain level on compression of the TrP, and in
cervical lateral flexion between electric point stimulation
and placebo applied to latent upper trapezius TrPs. The
null hypothesis was that there is no difference between
electric point stimulation and placebo. The alternate
hypothesis was that electric point stimulation is superior to
placebo.
Outcomes
The outcome measures were pressure pain threshold (PPT)
at the TrP, a numerical rating scale (NRS) assessing local
pain elicited over the TrP using a pain pressure algometer
(PPA) determined at the point sensation of pressure
changed to that of pain, and use of the cervical range of
motion device (CROM) to determine lateral cervical flexion
to the side opposite the TrP. An examiner masked to
treatment allocation of the participant assessed the
outcomes.
A pressure pain algometer (PPA) is a hand held device
that can measure deep tenderness and pressure pain
thresholds of muscles, bones and ligaments. It consists of
a gauge that is attached to a hard rubber tip 1 cm in
diameter. The gauge is calibrated in kg/cm2 and ranges
from 1 to 10 kg/cm2. The force recorded was the amount of
pressure that caused the sensation of pressure to change to
that of pain (PPT). Pressure pain threshold as determined
by a PPA has been shown to be reliable and valid (Nussbaum
and Downes, 1998; Antonaci et al., 1998; Reeves et al.,
1986; Delaney and McKee, 1993; Cathcart and Pritchard,
2006; Pontinen, 1998; Takala, 1990). The participant was
asked to indicate when the sensation of pressure changed
to that of pain. A trial was conducted over the forearm
muscles for the participant to understand what was
required. The rubber tip of the PPA was placed over the
marked TrP and held perpendicular to the muscle belly with
the gauge turned away from the participant. Pressure over
the TrP was increased steadily at a rate of 1 kg/cm2/s as
recommended by Fischer (1987). The examiner released
the pressure when pain was elicited as indicated by the
participant. This was repeated three times with a rest
period of 20 s between recordings. The mean of the three
measurements was used in data analysis.
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points
The NRS is a standard tool used to measure pain and
change in pain, and has been shown to be reliable and valid in
measuring sensitivity of a TrP (Jensen et al., 1986,1994,1999;
Salaffi et al., 2004; Williamson and Hoggart, 2005). During
determination of PPT when the participant indicated sensa-
tion of pressure changed to pain, the participant was asked to
grade the pain by selecting a number from 0 to 10 to repre-
sent the severity of pain. This was recorded three times and
the mean was used for data analysis.
The Cervical Range of Motion (CROM) instrument contains
three inclinometers, which measure motion in all three
planes. The device is strapped to the head and does not need
to be moved when measuring movements in different planes.
Research has shown the CROM to be useful in determination
of function, to monitor patient progress, and is reliable with
good construct validity (Norkin and White, 1985; Jordan,
2000; Youdas et al., 1991; Koning et al., 2008). The partici-
pant was asked to sit up straight and laterally flex their head
to the side opposite of the located TrP. The degree of lateral
flexion was then recorded. This was repeated three times
and the mean value was used in data analysis.
The clinician (HG) has over 25 years of experience
treating myofascial TrPs with electric point stimulation
(EPS). To improve quality of all the measurements the
examiner (AH) spent 10 h in training sessions with the
clinician, and about 2 weeks using the measures with his
fellow students so as to be confident and competent in
taking the measurements.
Randomisation
Randomisation was conducted a priori using the website
www.randomization.com. A clinician (HG) generated the
allocation sequence and sealed opaque envelopes were
prepared by HG prior to the study and numbered consecu-
tively. Participants were enrolled by AH. HG as the treating
clinician allocated participants the next available
numbered envelope. The examiner and participants were
masked to treatment, but the treating clinician was not.
Success of examiner blinding was ascertained by asking the
examiner if he was able to guess subject allocation to group
and he stated he was not able to do so.
Procedure
On arrival for the study the volunteer was screened for
eligibility by the examiner (AH). The treating clinician (HG)
determined if the volunteer had a latent TrP in the upper
trapezius muscle and reviewed the volunteer’s medical
history. If there was more than one latent TrP, the most
tender was chosen and marked with a cross using a skin-
pencil. After locating and marking the TrP the clinician
exited the room.
The examiner determined if the volunteer’s pain over
the TrP was at least 4 on the NRS with pressure. If so, the
volunteer signed the consent form and was enrolled in the
study. The examiner took pre-treatment measurements of
PPT, pain sensitivity of the TrP, and lateral cervical flexion
range as described above. Participants were not informed
of their scores throughout the study to prevent participant
bias influencing the results. At this point the examiner
exited the room and the treating clinician entered.
351
The clinician explained to the participant the procedure
for the electric point stimulation, and that they would
receive one of two types of stimulation. They were not told
that one was a placebo treatment. One was explained as
normal TENS with which they would feel a mild tingling
sensation, the other being microcurrent there would be no
tingling sensation felt. Two different types of EPS instru-
ments were shown to the patient to re-enforce the fact
that two types of EPS were being tested. The sounds and
light of the instrument to be used were then demonstrated
on the participant’s forearm. The clinician opened the next
consecutively numbered envelope and the marked TrP was
treated with active or placebo stimulation for 3 min as
described above, and exited the room. The examiner again
entered the room and post-treatment values were assessed
5 min after treatment in the same manner as pre-treatment
data were collected.
Statistical methods
Data were analysed with GraphPad Instat version 3.0 for
Windows (GraphPad Software, San Diego California USA,
www.graphpad.com). A normal distribution of the data was
assessed by the KolmogaroveSmirnov test (p > 0.05).
Baseline characteristics were compared between groups
using the independent t-test for continuous level data, and
the c2test was used for non-continuous level data. The
mean change from pre-test to post-test for each of the
outcomes was compared between the groups using the
independent t-test. Statistical analysis was conducted at
a 95% confidence interval, and p < 0.05 was considered
statistically significant.
Results
Figure 1 shows participant flow through the study. Thirteen
baseline demographic and clinical characteristics of each
group are shown in Table 1. All participants in each group
were included in each analysis. Due to the number of zero
cells for the marital status variables we were unable to
calculate statistical significance. However, on comparing
the numbers in each category for each group it appears the
categories were equal across groups. Therefore there was
Screened (n=78)
Excluded (n=18)
No trigger point (n=11)
NRS below 4 (n=6)
Psychosocial issues (n=1)
Randomised (n=60)
Allocated to EPS (n=30) Allocated to placebo (n=30)
Received EPS (n=30) Received placebo (n=30)
Analysed (n=30) Analysed (n=30)
Figure 1 Participant flow
352 H. Gemmell, A. Hilland

Table 1 Baseline demographic and clinical characteristics.

Variable Placebo EPS Statistic p Value
Age (SD) 25.6 (4.6) 24.2 (2.5) t Z 1.45, df Z 44 0.16
Gender (%) Females: 15 (50.0) Females: 13 (43.3) c2 Z 0.07, df Z 1 0.79
Males: 15 (50.0) Males: 17 (56.7)
Marital status (%) Married: 2 (6.7) Married: 0 (0) Unable to calculatea
Divorced: 0 (0) Divorced: 0 (0%)
Separated: 0 (0) Separated: 0 (0)
Single: 23 (76.7) Single: 28 (93.3)
Partner: 5 (16.7) Partner: 2 (6.7)
Tobacco use (%) Yes: 7 (36.7) Yes: 11 (23.3) c2 Z 0.71, df Z 1 0.40
No: 23 (63.3) No: 19 (76.7)
BMI (SD) 24.2 (3.9) 23.8 (4.7) t Z 0.35, df Z 56 0.73
NRS (SD) 4.5 (0.8) 4.7 (1.1) t Z 1.10, df Z 52 0.28
PPT (SD) 4.0 (1.4) 4.0 (1.4) t Z 0.02, df Z 58 0.98
CROM (SD) 43.8 (6.6) 46.2 (8.5) t Z 1.23, df Z 58 0.22
Age in years, PPT in kg/cm2, CROM e cervical lateral flexion in degrees.
a
Due to the number of zero cells unable to calculate.

no difference between the groups in any of the baseline
variables (p > 0.05).
Comparison between the groups for each outcome
measure relative to the pre-test to post-test change score is
shown in Table 2. The EPS group increased mean PPT by
0.49 (0.99) kg/cm2, while the placebo group increased
mean PPT by 0.45 (0.99) kg/cm2. The difference between
the groups was not statistically significant (t Z 0.1564,
p Z 0.8762, 95% CI Z 0.84 to 0.91). The EPS group had
a mean decrease in pain on pressure over the TrP of 0.93
(0.87) points, while the placebo group had a mean decrease
in pain of 0.23 (0.97) points. The difference between the
groups was significant (t Z 0.7004, p Z 0.005, 95%
CI Z 1.176 to 0.2338). Due to the significant difference
between the groups on pain, effect size was calculated for
both groups. The effect size for the active group was
d Z 0.93 and for the placebo group it was d Z 0.23. On
cervical lateral flexion away from the side of the involved
TrP the EPS group had a mean improvement of 2.87 (4.55)
degrees, compared to a mean improvement of 1.99 (2.49)
degrees in the placebo group. The difference between the
groups was not significant (t Z 0.9185, p Z 0.3621, 95%
CI Z 0.31 to 6.88).
No adverse effects were reported by any participant in
either group.
Discussion
To our knowledge this is the first study to compare electric
point stimulation type of TENS to placebo for latent TrPs.
The results show that EPS is superior to placebo for
reduction in pain on pressure over the TrP with a large
effect size (d Z 0.93). However, the null hypothesis cannot
be completely rejected as the results for PPT and cervical
ROM indicate there is no difference between EPS and
placebo in treating upper trapezius TrPs.
A longer follow up with multiple treatments may have
produced a different result. However, a recent systematic
review (Vernon and Humphreys, 2008) concluded that there
is moderate-to-high quality evidence that immediate clin-
ical improvements are achievable with a single session of
spinal manipulation. They feel the benefit of single session
trials of treatment can be viewed in two ways. The first is
that these trials provide a form of proof of concept in that
they indicate if a single dose of the treatment achieves an
acceptable level of intended outcome. Secondly, these
studies provide evidence of the outcome that can be
expected with each session of the treatment, at least for
the first treatment. Further, Lewit (2008) suggests that
musculoskeletal dysfunctions such as manipulable lesions
and TrPs are reversible and, therefore, usually react
immediately. This suggests that if the treatment effect is
large enough one treatment should be adequate to
demonstrate a difference between the groups.
Beecher (1959) coined the term “placebo effect” during
the 2nd World War when he ran out of morphine and gave
saline injections instead, but told the soldiers it was
morphine. He obtained a 35% response rate based on
expectation. It is now known that placebo rates vary. A
review (Walach et al., 2005) of 141 long-term randomised
controlled trials found non-specific effects accounted for

Table 2 Baseline to post-test change between the groups on each outcome.

Outcome EPS mean change Placebo mean change 95% CI t-test p Value
PPT 0.49 (0.99) 0.45 (0.98) 0.84 to 0.91 0.1564 0.8762
NRS 0.93 (0.87) 0.23 (0.97) 1.18 to 0.22 0.7004 0.0047*
C Lat Flex 2.87 (4.55) 1.99 (2.49) 0.31 to 6.88 0.9185 0.3621
*Significant p < 0.05.
PPT in kg/cm2; pain graded on a numerical rating scale from 0 to 10; C Lat Flex in degrees; t-test Z independent t-test.
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points
nearly 60% of all treatment effects across disease cate-
gories and a wide variety of interventions. One of the
difficulties in manual therapy is in using a credible placebo.
The type of placebo we used in the current study may be
challenged as both groups were subjected to pressure with
the EPS device and even light pressure may stimulate
mechanoreceptors to affect the pain response. However,
the placebo group did not receive any electrical stimulation
and we feel the placebo was adequate for our purposes.
Future studies could include a third arm of no treatment as
a control for natural history, but the question remains is it
really possible to have a no treatment group as some
interaction occurs between the participant and
investigators.
Based on the effect size obtained with pain over the TrP
(d Z 0.93), alpha set at 0.05, two-sided design, and power
of 0.8, 33 participants per group were needed for adequate
power to detect a statistically significant difference. With
30 subjects per group we feel the study had adequate
power.
While the clinician had extensive experience in diag-
nosing and treating myofascial TrPs, the examiner had
limited experience in using the outcome measures.
However, we feel adequate training was given and
adequate practice was obtained with the outcome
measures before the study and that this did not act as
a limitation to the study.
Conclusion
EPS is superior to placebo in reducing pain on compression
over upper trapezius TrPs, but is no better than placebo in
improving PPT or increasing cervical ROM.
Conflict of interest statement
The authors state they have no conflict of interest including
any financial, personal or other relationships with other
people or organisations within three years of beginning the
submitted work that could inappropriately influence, or be
perceived to influence, their work.
References
Antonaci, F., Sand, T., Lucas, G.A., 1998. Pressure algometry in
healthy subjects: inter-examiner variability. Scand. J. Rehabil.
Med. 30, 3e8.
Audette, F.F., Wang, F., Smith, H., 2004. Bilateral activation of
motor unit potentials with unilateral needle stimulation of
active myofascial trigger points. Am. J. Phys. Med. Rehabil. 83,
368e374.
Baldry, P.E., 2005a. Neurophysiology of pain. In: Baldry, P.E. (Ed.),
Acupuncture, Trigger Points and Musculoskeletal Pain. Churchill
Livingstone, Edinburgh.
Baldry, P.E., 2005b. Neurophysiological pain-suppressing effects of
acupuncture and TENS. In: Baldry, P.R. (Ed.), Acupuncture,
Trigger Points and Musculoskeletal Pain. Churchill Livingstone,
Edinburgh.
Beecher, H., 1959. Measurement of Subjective Responses. Oxford
University Press, New York.
Cathcart, S., Pritchard, D., 2006. Reliability of pain threshold
measurement in young adults. J. Headache Pain 7, 21e26.
353
Cooper, B.C., Alleva, M., Cooper, D.L., Lucente, F.E., 1986. Prev-
alence of myofascial pain dysfunction: analysis of 476 patients.
Laryngoscope 96, 1099e1106.
Delaney, G.A., McKee, A.C., 1993. Inter- and intra-rater reliability of
the pressure threshold meter in the measurement of myofascial
trigger point sensitivity. Am. J. Phys. Med. Rehabil. 72, 136e139.
Dommerholt, J., Bron, C., Franssen, J., 2006. Myofascial trigger
points: an evidence-informed review. J. Man. Manip. Ther. 14,
203e221.
Drewes, A.M., Jennum, P., 1995. Epidemiology of myofascial pain,
low back pain, morning stiffness and sleep-related complaints
in the general population. J. Musculoskelet. Pain 3, s121.
Fischer, A.A., 1987. Pressure algometry over normal muscles.
Standard values, validity and reproducibility of pressure
threshold. Pain 30, 115e127.
Gerwin, R.D., 1995. A study of 96 subjects examined both for
fibromyalgia and myofascial pain. J. Musculoskelet. Pain 3,
s121.
Gerwin, R.D., Shannon, S., Hong, C.-Z., Hubbard, D., Gevirtz, R.,
1997. Inter-rater reliability in myofascial trigger point exami-
nation. Pain 69, 65e73.
Graff-Radford, S.B., Reeves, J.L., Baker, R.L., Chiu, D., 1989.
Effects of transcutaneous electrical nerve stimulation on myo-
fascial pain and trigger point sensitivity. Pain 37, 1e5.
Han, S.C., Harrison, P., 1997. Myofascial pain syndrome and trigger
point management. Reg. Anaesth. 22, 89e101.
Hanten, W.P., Olson, S.L., Butts, N.L., Nowicki, A.L., 2000. Effec-
tiveness of a home programme of ischemic pressure followed by
sustained stretch for treatment of myofascial trigger points.
Phys. Ther. 80, 997e1003.
Hong, C.-Z., 1994. Persistence of local twitch response with loss of
conduction to and from the spinal cord. Arch. Phys. Med.
Rehabil. 75, 12e16.
Hou, C.R., Tsai, L.C., Cheng, K.F., Chung, K.C., Hong, C.-Z., 2002.
Immediate effects of various physical therapeutic modalities on
cervical myofascial pain and trigger-point sensitivity. Arch.
Phys. Med. Rehabil. 83, 1406e1414.
Howe, T.E., Johnson, M.I., Sluka, K.A., Walsh, D.M., 2008. Trans-
cutaneous Electrical Nerve Stimulation for Acute Pain (Protocol).
Available from:. The Cochrane Library http://www3.
interscience.wiley.com/cgi-bin/mrwhome/106568753/home.
Hsueh, T.C., Cheng, P.T., Kuan, T.S., Hong, C.-Z., 1997. The
immediate effectiveness of electrical nerve stimulation and
electrical muscle stimulation on myofascial trigger points. Am.
J. Phys. Med. Rehabil. 76, 471e476.
Huguenin, L.K., 2004. Myofascial trigger points: the current
evidence. Phys. Ther. Sport 5, 2e12.
Jensen, M.P., Karoly, P., Braver, S., 1986. The measurement of
clinical pain intensity: a comparison of six methods. Pain 27,
117e126.
Jensen, M.P., Turner, J.A., Romano, J.M., 1994. What is the
maximum number of levels needed in pain intensity measure-
ments? Pain 58, 387e392.
Jensen, M.P., Turner, J.A., Romano, J.M., Fischer, L.D., 1999.
Comparative reliability and validity of chronic pain intensity
measures. Pain 83, 157e162.
Jordan, K., 2000. Assessment of published reliability studies for
cervical spine range of motion measurement tools. J Manipu-
lative Physiol. Ther. 23, 180e195.
Kane, K., Taub, A., 1975. A history of local electrical analgesia.
Pain 2, 125e138.
Koning, H.P., Huvel, S.P., Staal, J.B., Englesman, C.M.,
Hendriks, J.M., 2008. Clinimetric evaluation of active range of
motion measures in patients with non-specific neck pain:
a systematic review. Eur. Spine J. 17, 905e921.
Kramer, S., Winterhalter, K., Schober, G., et al., 2009. Charac-
teristics of electrical skin resistance at acupuncture points in
healthy humans. J. Altern. Complement. Med. 15, 495e500.
354
Lewit, K., 2008. Lessons for the future. Int. Musculoskelet. Med.
30, 133e140.
Melzack, R., Wall, P.D., 1965. Pain mechanism: a new theory.
Science 150, 917e979.
Mense, S., Simons, D.G., 2001. Myofascial pain caused by trigger
points. In: Darcay, P.J., Napora, L.S. (Eds.), Muscle Pain e
Understanding its Nature, Diagnosis and Treatment. Lippincott
Williams & Wilkins, Philadelphia.
Norkin, C.C., White, D.J., 1985. Introduction to Goniometry. FA
Davis Company, Philadelphia.
Nussbaum, E.L., Downes, L., 1998. Reliability of clinical pressure
pain algometric measurements obtained on consecutive days.
Phys. Ther. 78, 160e169.
Pontinen, P.J., 1998. Reliability, validity and reproducibility of
algometry in the diagnosis of active and latent tender spots and
trigger points. J. Musculoskelet. Pain 6, 160e169.
Reeves, J.L., Jaeger, B., Graff-Radford, S.B., 1986. Reliability of
the pressure algometer as a measure of myofascial trigger point
sensitivity. Pain 24, 313e321.
Rickards, L.D., 2006. The effectiveness of non-invasive treatments
for active myofascial trigger point pain: a systematic review of
the literature. Int. J. Osteopath. Med. 9, 120e136.
Rushton, D.N., 2002. Electrical stimulation in the treatment of
pain. Disabil. Rehabil. 24, 407e415.
Salaffi, F., Stancati, A., Silvestri, C.A., Ciapetti, A., Grassi, W.,
2004. Minimal clinically important changes in chronic musculo-
skeletal pain intensity measured on a numerical rating scale.
Eur. J. Pain 8, 283e291.
Simons, D.G., Travell, J.G., Simons, L.S., 1999. Myofascial Pain and
Dysfunction: The Trigger Point Manual. In: . Upper Half of Body,
vol.. 1. Lippincott Williams & Wilkins, Philadelphia.
H. Gemmell, A. Hilland
Simons, D.G., 2002. Understanding effective treatments of myo-
fascial trigger points. J. Bodyw. Mov. Ther. 6, 81e88.
Sluka, K.A., Walsh, D., 2003. Transcutaneous electrical nerve
stimulation: basic science mechanisms and clinical effective-
ness. J. Pain 4, 109e121.
Sola, A.E., Rodenberger, M.L., Gettys, B.B., 1955. Incidence of
hypersensitive areas in posterior shoulder muscles: a survey of
two hundred young adults. Am. J. Phys. Med. 34, 585e590.
Sola, A.E., Williams, R.L., 1956. Myofascial pain syndromes.
Neurology 6, 91e95.
Takala, E.P., 1990. Pressure pain threshold on upper trapezius and
levator scapulae muscles. Repeatability and relation to subject
symptoms in a working population. Scand. J. Rehabil. Med. 22,
63e69.
Tough, E.A., White, A.R., Richards, S., Campbell, J., 2007. Vari-
ability of criteria used to diagnose myofascial trigger point pain
syndrome e evidence from a review of the literature. Clin. J.
Pain 23, 278e286.
Vernon, H., Humphreys, B.K., 2008. Chronic mechanical neck pain
in adults treated by manual therapy: a systematic review of
change scores in randomised controlled trials of a single session.
J. Man. Manip. Ther. 16, E42eE52.
Walach, H., Sadaghiani, C., Dehm, C., Bierman, D., 2005. The
therapeutic effect of clinical trials: understanding placebo
response rates in clinical trials e a secondary analysis. BMC
Med. Res. Methodol. 5, 26. 10.1186?1471-2288-5-26.
Williamson, A., Hoggart, B., 2005. Pain: a review of three
commonly used pain rating scales. J. Clin. Nurs. 7, 798e804.
Youdas, J.W., Carey, J.R., Garett, T.R., 1991. Reliability of
measurements of cervical range of motion e comparison of
three methods. Phys. Ther. 71, 98e104.