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5Th National Congress of the Italian Society of Physiotherapy Milan, Italy Archives of Physiotherapy 2016, 6(Suppl 1):11 DOI 10.1186/s40945-016-0022-4 MEETING ABSTRACTS Open Access 5th National Congress of the Italian Society of Physiotherapy Milan, Italy. 3–4 October 2015 Published: 14 October 2016 S1 S2 Criteria for exercises selection in subjects with low back pain Recent advances in pathophysiology and treatment of myofascial Alessandro Aina ([email protected]) trigger points Physiotherapist, Dip. MDT, private practice, Milan, Italy Marco Barbero ([email protected]) Archives of Physiotherapy 2016, 6(Suppl 1):S1 Rehabilitation Research Laboratory, Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of From the '70s until the '90s, in clinical trials aimed at studying the ef- Southern Switzerland, SUPSI, Manno, Switzerland fects of conservative interventions in people with low back pain, par- Archives of Physiotherapy 2016, 6(Suppl 1):S2 ticipants were randomly allocated to different treatment groups without a preliminary assessment that went beyond symptoms The original and the most commonly accepted definition of myofas- localization. The initial assumption was that patients exhibiting simi- cial pain syndrome has been formulated by Simons and Travell in lar symptoms localization should be considered as a unique group. the first volume of The Trigger point Manual edited in 1983 [1]. The Consequently, the effects of different interventions were similar and authors defined the myofascial pain syndromes as a regional pain guidelines merely suggested “Stay active”. characterized by the presence of one or more myofascial trigger Since the '80s some physiotherapists began to develop a number of points (MTrP). A MTrP is a distinctive clinical characteristic of this evaluation tests in order to identify specific subgroups among people painful syndrome and it is defined as a hyperirritable palpable nod- with low back pain and develop targeted treatments for each sub- ule contained in the skeletal muscle fibers. It can produce referred group. However, in the early 2000s, the Assessment Diagnosis Treat- pain, either on digital compression or spontaneously. If stimulated ment Outcome (ASTO) model, developed by K. Spratt [1], stated that with dry needling or snapping palpation it may exhibit a typical each step must be validated before proceeding to the next. muscle fasciculation or jump sign. This talk will: The literature suggests that MTrPs are extremely common and can be considered both a primary cause of a MPS or a secondary pain 1. Illustrate the following assessment and classification generator in patients affected by a principal musculoskeletal disorder approaches: A) Mechanical diagnosis and therapy [2], B) [2]. Before the mid-1990s, key elements regarding the pathophysi- Treatment based classification [3], C) Movement system ology were unrecognized. Subsequently research studies have made impairment [4], D) Cognitive functional therapy [5], E) Patho- the pathophysiology of myofascial pain syndrome much better anatomic based classification [6]. understood. Three main hypotheses have been provided: energy cri- 2. Provide criteria for the selection of therapeutic exercises. sis theory, muscle spindle concept and the motor endplate hypoth- 3. Highlight the possible overlaps and synergies among different esis [3]. Additionally, recently Mense et al. presented an integrated approaches [7]. hypothesis which is a work in progress and updated as new evidence emerges [4]. This combines recent electrophysiological and histo- pathological research findings. References Various methods of MTrP treatment are available but currently no 1. Spratt K, Statistical relevance, in Orthopaedic Knowledge Update: Spine 2, clinical guidelines are available and clinicians are required to balance e.a. D.F. Fardon, Editors, Editor. 2002, The American Academy of the available evidence, their clinical experience and the patient’s Orthopaedic Surgeons: Rosemont, Illinois, p. 497–505; in Donelson R. preferences. Treatment approaches can be considered as invasive Rapidly reversable low back pain. SelfCare First, LLC, Hanover, New and non-invasive. Dry needling or intramuscular stimulation, is an in- Hampshire, First edition, 2007. vasive technique in which a thin needle is used to penetrate the skin 2. McKenzie RA, May S. The lumbar spine: mechanical diagnosis and and stimulate the MTrP. therapy. 2nd edition. Waikanae, New Zealand: Spinal Publications, 2003. The expected therapeutic effect is to release the taut band and re- 3. Delitto A, et al. A treatment-based classification approach to low back duce the irritability of the spot tenderness. Together with injections syndrome: identifying and staging patients for conservative treatment. (local anaesthetics, steroids, Botulinum toxin A) these are among the Phys Ther. 1995;75(6):470–489. most common treatments for myofascial pain syndrome. 4. Sahrmann S. Diagnosis and treatment of movement impairment Recently dry needling gained popularity among physiotherapists and syndromes. St. Luis, MO: Mosby, Inc., 2002. three systematic reviews on the efficacy have been completed [5–7]. 5. O'Sullivan P. Diagnosis and classification of chronic low back pain According to the available systematic reviews dry needling should be disorders: maladaptive movement and motor control impairment as considered the first choice treatment but due to the small number of underlying mechanism. Man Ther. 2005;10(4):242–255. high quality trials additional research requires to be undertaken. 6. Petersen T, et al. Diagnostic classification of non-specific low back pain. A Non-invasive treatments include various manual techniques such as new system integrating patho-anatomic and clinical categories. Physi- ischemic compression or manual stretching, and modalities like ultra- other Theory Pract. 2003;19:213–37. sound and low-level laser therapy. No systematic reviews are avail- 7. Karayannis NV et al., Movement-based subgrouping in low back pain: able for these treatments. However, some trials indicated that synergy and divergence in approaches. Physiotherapy. 2015 Jul 3 [Epub manual treatment of MTrPs might reduce the pressure pain threshold ahead of print]. of spot tenderness and the VAS score [8, 9]. © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Archives of Physiotherapy 2016, 6(Suppl 1):11 Page 2 of 42 References these results may be justified by their poor methodological quality 1. Travell JG and Simons DG. Myofascial pain and dysfunction: the trigger assessed by using the Cochrane Scale. point manual. Baltimore; London: Williams & Wilkins, 1983. Despite the above background, the aim of our study is to analyze if a 2. Fricton JR. Clinical care for myofascial pain. Dent Clin North Am. 1991;35:1–28. manual therapy approach is effective for improving the respiratory 3. Simons DG. Clinical and etiological update of myofascial pain from mechanics of patients with diagnosis of amyotrophic lateral sclerosis trigger points. J Musculoskel Pain. 1996;4:97–125. (ALS). Respiratory issues are a common cause of comorbidities and 4. Mense S, Simons DG and Russell IJ. Muscle pain : understanding its nature, mortality in patients affected by this disease [4]. The decreased pa- diagnosis, and treatment. Philadelphia: Lippincott Williams & Wilkins, 2001. tient’s breathing capacity is, in part, due to the progressive motoneu- 5. Cotchett MP, Landorf KB and Munteanu SE. Effectiveness of dry needling rons degeneration. The increase of the chest stiffness, because of and injections of myofascial trigger points associated with plantar heel adaptation of bone and ligament tissues to a prolonged hypomobi- pain: a systematic review. J Foot Ankle Res. 2010;3:18. lity, further worsens this clinical presentation of restrictive nature 6. Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM [5,6]. Strongly supported clinical procedures are the non-invasive and Tucker M. Effectiveness of Dry Needling for Upper Quarter ventilation (NIV), the mechanic inspiration-expiration techniques, the Myofascial Pain: A Systematic Review and Meta-analysis. J Orthop Sports cough assisted techniques and clearance of the respiratory secretions Phys Ther. 2013 Sep;43(9):620–34. [7]. Based on our knowledge no articles so far investigated the effi- 7. Tough EA, White AR, Cummings TM, Richards SH and Campbell JL. cacy of manual techniques applied on the spinal thoracic joints with Acupuncture and dry needling in the management of myofascial trigger the aim to reduce the stiffness around this anatomical area with the point pain: a systematic review and meta-analysis of randomised controlled final goal to improve the breathing capacity. This modality of treat- trials. Eur J Pain. 2009;13(1):3–10. ment has already been studied in patients affected by chronic ob- 8. Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, Llamas-Ramos I, structive pulmonary disease [5]. Plaza-Manzano G, Ortega-Santiago R, Cleland J and Fernandez-de-Las- Some
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