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

Article Outline

• Abstract
• Methods
• Results
  • Manual Therapies
    • Systematic Reviews of Manual Therapies
    • Practice Guidelines on Manual Therapy
    • RCTs of Manual Therapy
  • Conclusion: RCTs
    • Case Reports of Manual Therapy
    • Clinical Reviews of Manual Therapy
  • Critique of Clinical Reviews
    • • Manual Therapies
      • Other therapies
    • Evidence Synthesis of Manual Therapies
    • Clinical Practice Recommendations of Manual Therapies
  • Other Conservative Therapies
    • Systematic Reviews of Other Conservative Therapies
    • RCTs of Other Conservative Therapies
      • Acupuncture
      • Laser
      • Electrotherapy
      • Exercise
      • Spray and stretch
      • Ultrasound
    • Evidence Synthesis of Other Conservative Therapies
    • Clinical Practice Recommendations
• Conclusion
• Appendix A. Reference list of case studies of conservative treatments of MPS/TrPs
• References
• Copyright

Abstract 

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.

Key Indexing Terms: Myofascial Pain Syndromes, Myofascial Trigger Points, Chiropractic, Musculoskeletal Manipulations

Ever since the seminal work of Travell and Rinzler¹ 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 specialists³ 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 Nimmo⁵, ⁶, ⁷ represents the earliest and perhaps still most established thinking on this topic among chiropractors. Cohen and Gibbons⁸ describe his work as “a conceptual leap from moving bones to working with muscles that move bones.” Schneider⁹, 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, ¹⁰, ¹¹, 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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Methods 

The search strategy for this review was constrained by the need to identify only those studies of chiropractic treatments (manual therapy and other conservative therapies) that were not directed at clinical complaints associated with any of the specific body regions that have been designated as other reviews in the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) process. In other words, no study was selected of the effect of a chiropractic treatment specifically indicated for back pain, neck pain, upper limb pain (shoulder, elbow, wrist), and lower limb pain (hip, knee, ankle, and foot) of any kind (ie, for any category of diagnosis). Only studies of chiropractic treatments for MPS and TrPs were considered. Therefore, the inclusion criteria for this search were as follows: manual therapies, trigger points, myofascial pain syndrome (MeSH headings: musculoskeletal manipulations, myofascial pain syndrome [not exploded to temporomandibular joint]), conservative therapies, laser, acupuncture, ultrasound (US), electrotherapy, naturopathy; 1965 to 2007; English, German; human studies.

After the primary search was conducted, a number of secondary searches were conducted based upon “related links,” especially emphasizing systematic or clinical reviews, randomized clinical trials, and conservative treatments (vs musculoskeletal manipulations only), as well as searches of additional works by the authors identified in the primary search. Finally, citation reviews were conducted manually to identify any additional suitable studies.

This search was conducted in the PubMed; Cumulative Index to Nursing and Allied Health Literature; Index to Chiropractic Literature (ICL); Manual, Alternative, and Natural Therapy System (MANTIS); Excerpta Medica Database; National Guidelines Clearinghouse; Database of Abstracts of Reviews of Effects; and Turning Research Into Practice databases. Selected publications were rated on the Oxford Rating Scale¹⁹, ²⁰ as well as the Scottish Intercollegiate Guidelines Network (SIGN) Checklist (Fig 1).

Fig 1. Rating scales for included studies.

A. The Oxford Rating Scale.19, 20
1a: Systematic review, with homogeneity of RCT’s.
1b: Individual RCT with narrow confidence interval.
1c: All or none.
2a: Systematic review, with homogeneity of cohort studies.
2b: Individual cohort study (including low quality RCT; eg <80% follow-up).
2c: “Outcomes Research”; Ecological studies.
3a: Systematic review with homogeneity of case-control studies.
3b: Individual case-control study.
4: Case-series (and poor quality cohort and case-control studies).
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”.
B. The SIGN Checklist.
1. ++ = All or most methodological criteria have been fulfilled/bias has been maximally reduced.
2. + = Some of the criteria have been fulfilled/bias has been somewhat reduced.
3. − = Few or no criteria fulfilled/bias is clearly present.

This review accepted all levels of published evidence for narrative description: clinical guidelines, systematic reviews, clinical trials, cohort or case series, case studies, and clinical reviews. For evidence rating, recommendations were constructed and rated according to the Oxford Rating Scale¹⁹, ²⁰ as follows:

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Results 

Manual Therapies 

Two completed systematic reviews were identified.²¹, ²² These reviews were rated (Oxford Scale) as 1a evidence with a 2+ quality rating on the SIGN Checklist.

Fernandez de las Penas et al²¹ used the following selection criteria for acceptable studies:

“clinical or randomized controlled trials in which some form of manual therapy (strain/counterstrain, ischemic compression, transverse friction massage, spray and stretch, muscle energy technique) was used to treat (myofascial trigger points) MTrPs” (p29).

Mobilization and manipulation were apparently not explicitly included. It should be noted that the criterion applied to the “clinical category” in this search was “MTrPs,” although MPS was referenced later in their review. No additional, more specific criteria related to clinical complaints in any of the body regions (ie, back pain, neck pain, limb pain, etc) were used. It would appear that this search strategy is consistent with the one devised for this review, as other CCGPP reviews dealt with the chiropractic management of pain complaints specific to these body regions.

Fernandez de las Penas et al²¹ identified 7 acceptable trials (SIGN = 2+/Oxford Scale ratings = 1b), 4 of which obtained a sufficiently high quality score (>5/10 on the Physiotherapy Evidence Database Scale).

The interventions used in these studies were as follows (number of studies in parentheses): spray and stretch (2), soft tissue massage (2), ischemic compression (2), occipital release exercises (1), strain/counterstrain (SCS) (1), and myofascial release (1). An important finding was:

“Only 2 studies … test(ed) the specific efficacy (efficacy beyond placebo) of various manual therapies in the treatment of MPS (Gam et al²³ [massage] and Hanten et al²⁵ [occipital release]). These studies found no difference between interventions” (p30).²¹

Another important issue from this group of studies is the duration of treatment. Most of these studies (4) investigated only the immediate effects on pain and tenderness.²⁴, ²⁶, ²⁷, ²⁸ One study investigated the short-term treatment effects of ischemic compression vs exercises over 5 treatments,²⁵ whereas 2 investigated longer-term effects (6 months) of a course of, in one case, massage added to US therapy²³ and, in the other case, SCS in addition to exercises.²⁹ In both of the latter studies of a course of therapy, the manual therapy used (massage or SCS) was included among other therapies, making it impossible to identify the distinct contribution of the manual therapy to the reported outcomes.

Fernandez de las Penas et al²¹ conclude that there are very few randomized controlled studies (RCTs) of any type of manual therapy in the treatment of MTrP (MPS) and, as a result, “the hypothesis that manual therapies have specific efficacy beyond placebo in the management of MPS caused by MTrPs is neither supported or refuted by the research to date” (p33). They do acknowledge that there is some evidence for improvement in some groups within these trials and that this warrants further research.

In Rickards'²² review, the inclusion criteria included RCTs of a conservative (in this section: manual only) therapy for active TrPs, not latent TrPs, in which a patient-related pain outcome was used and in which an explicit diagnosis of TrP was made including at least local tenderness and a taut muscle band. Studies were rated on a 20-point scale; however, no cutoff score was used for inclusion. Rickards included the following studies: Chatchawan et al,³⁰ Fernandes de las Penas et al,³¹ Hanten et al,²⁸ Hou et al,²⁷ and Edwards and Knowles.³²

For the purposes of the present review, the following comments apply to this group of studies: (1) The study of Chatchawan et al³⁰ of massage therapies clearly identified the target group as chronic low back pain and would be included in the CCGPP review on low back pain. (2) The study of Fernandez de las Penas³¹ is included below. (3) The studies of Hanten et al and Hou et al are included in the review by Fernandez de las Penas et al above. (4) Edwards and Knowles' trial³² did not include a manual therapy (only active stretching and dry needling were investigated). Therefore, for manual therapies, Rickards' review does not add anything substantial to the present review.

A Cochrane Collaboration Protocol entitled “Non-invasive physical treatments of myofascial pain” (Kilkenny et al³³) was identified. This protocol currently contains no results. However, it was used as a source of additional references, particularly on published clinical trials and systematic reviews.

The following practice guidelines were identified:

In addition to Fernandez de las Penas et al,²³ our search identified 3 RCTs (Oxford Scale rating = 1b or 2b) of the effect of spinal manipulation on local paraspinal muscular tenderness in the dorsal spine (Terret and Vernon³⁴ [2+/2b]), cervical spine (Vernon et al³⁵ [2+/2b]), and lumbopelvic area (Cote et al³⁶ [2+/2b]). All 3 studies investigated only the immediate effect of the interventions on local muscular pain thresholds (electrical stimulus in Terret and Vernon³⁴ and pressure stimulus in Vernon et al³⁵ and Cote et al³⁶). Immediate and statistically significant increases in pain thresholds were found for spinal manipulation as compared with mobilization in the cervical and dorsal paraspinal muscles, but not in the lumbopelvic soft tissues.

Vicenzino et al³⁷ (2+/1b) reported on the immediate effect of a cervical mobilization on pressure pain threshold (PPT) of tender points on the lateral epicondyle in patients with “tennis elbow.” Only the mobilization (described as “manipulation” in this study) resulted in statistically significant increases in lateral epicondyle PPTs vs placebo and control conditions.

Greene et al³⁸ (2+/1b) investigated the effect of 4 different treatments given 3 times over 3 days on skin resistance levels. Subjects with thoracic TrPs were randomized to receive osteopathic manipulative treatment (OMT), laser treatment, OMT plus laser, and sham laser. No significant differences in effects were noted between these groups.

Atienza Meseguer et al³⁹ (2+/1b) studied 54 subjects with trapezius TrP treated with classic SCS, modified SCS, and control. Both treatment groups showed immediate improvement in PPT vs controls, but not vs each other.

Fryer and Hodgson⁴⁰ (2+/1b) compared manual pressure release to sham myofascial release in 37 subjects with upper trapezius myofascial TrPs. A statistically significant increase in PPT was obtained immediately after the intervention in the manual pressure group vs controls that was found to be due to a change in tissue sensitivity.

Fernandez-de-las-Penas et al³¹ (2+/1b) compared ischemic compression to transverse friction massage in 40 subjects with myofascial TrPs in the upper trapezius muscle. Both groups obtained significant improvement in PPT within 2 minutes. No difference was found between the groups.

Conclusion: RCTs 

A total of 14 RCTs were retrieved. Quality scores ranged widely for the 7 trials reviewed by Fernandes de las Penas et al.²¹ Ten of 14 trials we identified involved only immediate changes in TrP or tender point ratings. Two other trials reported outcomes for short courses of treatments over 3 to 5 days,²⁵, ³⁸ whereas 2 others reported outcomes at 6 months.²³, ²⁹ The outcomes of the “immediate” trials can be summarized as demonstrating effectiveness in reducing tenderness for spinal manipulation (2 of 3 trials), spray and stretch (2 trials), ischemic compression (3 trials), transverse friction massage (1 trial), and SCS (1 trial). One trial of mobilization failed to show any significant changes in tenderness scores vs controls. It would appear that there is moderately strong evidence to support the use of some manual therapies in the immediate relief of TrP tenderness.

The 2 trials of short-term effects (3-5 days) demonstrated the effectiveness of osteopathic manipulation and ischemic compression, respectively, in reducing TrP tenderness. One long-term trial reported that SCS demonstrates clinically important changes in TrP tenderness and general pain over 6 months, whereas the other showed that massage produced limited effect. It would appear that there is only limited evidence to support the use of manual therapies over longer courses of treatments in the management of TrPs and MPS.

Twenty-six case reports in the chiropractic literature were identified from ICL or MANTIS (Appendix A). These reports covered TrP treatments in patients with hand pain, low back pain due to a TrP in the quadratus lumborum muscle, wrist pain, fibromyalgia, upper quarter syndrome, MPS, and general TrPs.

Up-to-date clinical reviews⁴¹, ⁴², ⁴³, ⁴⁴, ⁴⁵, ⁴⁶ by noted experts in the field of myofascial pain have endorsed the use of a variety of manual therapies in the treatment of TrPs and MPS. These are classed as level 5 (Oxford Rating) evidence.

Harden⁴⁵ notes that the principle aims of therapy for MPS are relief of pain and inflammation, prevention of further injury, reducing spasm, correcting abnormal postures, and improving circulation. He endorses the following therapeutic modalities for accomplishing these aims:

Hong⁴¹ recommends that the first principle of treatment of MPS is the identification and treatment of the presumed primary lesion (section 1). Only after this has been done, and if there is persistence of pain from the active TrPs, should direct treatment to the TrPs be performed. Hong suggests that, at this point in the therapeutic process, release of muscle tightness is the first objective. He identifies 7 steps in the treatment process for the active TrPs themselves:

Hong places considerable importance on manual therapies for TrPs. He indicates the following as important aspects of manual therapy (p40):

Gerwin⁴² also endorses the treatment protocol that separately addresses therapies for the local TrP vs therapies for the perpetuating factors. In the former category, he specifically endorses manual TrP compression for focal TrP release, followed by myofascial release techniques for local stretching and then “therapeutic stretch” for the longer-range elongation of the body segments. In the case of perpetuating factors, he includes correction of postural faults as well as joint dysfunction. This should be followed by an active program of physical conditioning, stretching, and endurance, including preventative strategies. Unfortunately, no studies were provided as evidence for this approach.

Simons⁴⁴ reviews the mechanisms of TrP formation and perpetuation to guide the appropriate treatment approach. The therapies endorsed in his review are as follows:

Only the work of Lewit⁴⁷ is cited as support for this approach. Other noninvasive therapies that Simons merely mentions as additional to the approach described above include facilitatory techniques, acupuncture, SCS, microcurrent, US, and laser.

Alvarez and Rockwell's⁴³ review only provides a list of noninvasive treatment modalities that include acupuncture, osteopathic manual medicine techniques [sic], massage, acupressure, US, heat, ice, diathermy, transcutaneous electrical nerve stimulation (TENS), and “spray and stretch” techniques. For these modalities, no clinical trial evidence was provided. The only support was a reference to the authoritative work described in Travel and Simons'² manual.

Lavelle et al⁴⁶ endorse the following treatments as efficacious: spray and stretch, TENS, physical therapy, and massage.

Critique of Clinical Reviews 

Manual Therapies 

All 6 reviews from within the last 5 years endorsed manual therapies for TrP treatment in MPS. None of these reviews provided a single reference to a clinical trial to support this position. None of the 11 trials reviewed above was cited in any of these reviews. As such, there is discordance, even at the level of renowned experts' reviews, between the apparent consensus on the use and types of manual therapies in treating TrPs vs the evidence from the published literature.

Other therapies 

Only Harden⁴⁵ cites the clinical trial of Esenyel et al⁴⁸ (US + stretching vs dry needling + stretching vs stretching alone) and the case series of Simunovic et al⁴⁹ (laser therapy) as clinical studies of these sorts of therapies as well as the review of laser therapy by Gam et al.²³ The other reviews provide no support in the form of any clinical study for their recommendation on noninvasive therapies for TrPs.

Table 1, Table 2 summarize the literature retrieved in this review.

Table 1. Literature review: all studies

Table 2. Literature review: randomized clinical trials of manual therapy for MPS or TrPs (all rated as Oxford 1b, unless otherwise noted as 2b)

SMT, Spinal manipulation therapy.

Other Conservative Therapies 

Two published reviews were identified for treatment methods other than manual therapies.²², ⁵⁰ In Rickards'²² review, the inclusion criteria included RCTs of a conservative therapy for active TrPs, not latent TrPs, in which a patient-related pain outcome was used and in which an explicit diagnosis of TrP was made including at least local tenderness and a taut muscle band. Studies were rated on a 20-point scale; however, no cutoff score was used for inclusion. It should be noted that no trials for acupuncture were included in this review (below). A total of 18 trials were included in this review (Table 3, Table 4, Table 5, Table 6). Rickards'²² conclusions were based on the following schema:

Table 3. Studies of laser therapy from Rickards²² (n = 6 studies)

Table 4. Studies of electrotherapy from Rickards²² (n = 5 studies)

Table 5. Studies of magnet therapy form Rickards²² (n = 3 studies)

RMS, Repetitive magnetic stimulation.

Table 6. Studies of US therapy from Rickards²² (n = 4 studies)

Rickards' conclusions for each therapy were as follows:

It was noted that most trials involved either immediate or short-term effects and that much more research, especially on the longer-term effects, was needed.

Cummings and White⁵⁰ reviewed all trials up to 2000 of “Needling Therapies” for myofascial pain. Three of these trials involved what could be described as “standard” acupuncture typical of the type used by some chiropractors. This is distinguished from deep dry needling and any injection-type therapies that would not be standard chiropractic treatment approaches. For the present review, any trials that specifically identified one of the regional complaint areas in the CCGPP (ie, low back pain, neck pain) without specifying the treatment of TrPs were excluded (Table 7). Cummings and White⁵⁰ concluded that marked improvements were demonstrated in most treatment groups. However, dry needling techniques alone did not appear to be superior to other treatments in the treatment of myofascial TrPs. As well, they could not find evidence for a specific efficacy of these techniques beyond placebo. They called for more placebo-controlled trials.

Table 7. Studies of acupuncture therapy from Cummings and White⁵⁰ (n = 3)

IP, ;NSAID, nonsteroidal anti-inflammatory drug.

A Cochrane Collaboration Protocol entitled “Non-invasive physical treatments of myofascial pain” (Kilkenny et al³³) was identified. This protocol currently contains no results. However, it was used as a source of additional references, particularly on published clinical trials and systematic reviews.

Both Rickards²² and Cummings and White⁵⁰ used specific inclusion and exclusion criteria that resulted in the exclusion of numerous studies, either because they were not RCTs or for various methodologic reasons. These excluded trials will not be listed or reviewed here, as that would both duplicate and undermine the methods and conclusions of these reviews. Several trials have been identified in the present search that either have been published since these reviews or were not identified at all in these reviews (probably because of the inclusion of MANTIS and ICL databases in the present search) in the following areas:

Acupuncture 

There is some additional evidence that a course of deep acupuncture to TrPs is effective in the treatment of myofascial pain for up to 3 months (Table 8).

Table 8. Additional acupuncture trials

Laser 

The study of Greene et al³⁸ of laser vs osteopathic manipulation (OMT) alone vs OMT + laser vs sham laser to thoracic paraspinal muscle TrPs over 3 days involved measuring only local skin resistance. No measures of pain or tenderness response were made. This study would not have qualified for Rickards' review and does not, as well, for the present review.

Olavi et al⁷⁵ compared infrared laser to placebo laser over various active TrPs located throughout the body. Pressure pain thresholds were measured immediately after and then 15 minutes after treatment. A statistically significant difference favoring the laser group was found, especially at 15 minutes.

Electrotherapy 

No additional studies were retrieved.

Exercise 

No additional studies not already included in Rickards²² under “physical therapies” were retrieved.

Spray and stretch 

The study of Hou et al²⁷ was included in section 3 and was included in the reviews of both Fernandes de las Penas et al²¹ and Rickards³³ under the category of manual therapy. This is because most treatment groups received ischemic compression with or without a variety of other physiologic therapies. One of these therapies was spray and stretch, making Hou et al²⁷ the only published clinical trial to investigate this therapy. Hou et al found that the addition of spray and stretch to ischemic compression provided immediate benefit in reducing TrP sensitivity. There are no other published clinical trials of spray and stretch therapy for management of pain from TrPs. Notwithstanding this, it is often cited by clinical experts as a valuable treatment of TrPs.

Ultrasound 

Srbely and Dickey⁷⁶, ⁷⁷ applied therapeutic-intensity vs low-intensity US to trapezius TrPs in 44 subjects. Pressure pain thresholds over trapezius TrPs increased 44% (14.2%) in the first group, whereas no increase was obtained in the second group.

Table 9 summarizes the evidence retrieved in this review.

Table 9. Literature review: all studies of other conservative therapies

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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).

Table 10. Summary of recommendations

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Appendix A. Reference list of case studies of conservative treatments of MPS/TrPs 

Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol 2005 Jul;174(1):155-60.

Brewer G, Kampschroeder F, Moore L. Trigger point and transverse frictional massage: a case report. Chiropr 1990;6:40-42.

Crawford JS, Simpson J, Crawford P. Myofascial release provides symptomatic relief from chest wall tenderness occasionally seen following lumpectomy and radiation in breast cancer patients. Int J Radiat Oncol Biol Phys 1996 Mar 15;34(5):1188-9.

Daniells E, Wood T. Chiropractic care protocol versus stretching in the treatment of active trigger point in the extensor muscles of the hand and fingers. Toronto, ON: Proceedings of the World Federation of Chiropractic, 7th Biennial Congress 2003:311-312.

Davies C. Trigger point therapy for carpal tunnel syndrome: self-applied massage of the forearms and scalenes. J Am Chiropr Assoc 2002;39:18-23.

De Franca G, Levine L. Quadratus lumborum and low back pain. J Manipulative Physiol Therap 1991;14:142-149.

Grobli C, Dejung B. Non-medical therapy of myofascial pain. Schmerz 2003;17:475-480.

Han SC, Harrison P. Myofascial pain syndrome and trigger point management. Reg Anaesth 1997;22:89-101.

Hong C. Specific sequential myofascial trigger point therapy in the treatment of a patient with myofascial pain syndrome associated with reflex sympathetic dystrophy. Australas Chiropr Osteopath 2000;9:7-11.

Howitt SD, Wong J, Zabukovec S. The conservative treatment of trigger thumb using Graston Technique and Active Release Techniques®. J Can Chiropr Assoc 2006;50:249-254.

Hsieh H, Hong C. Effect of chiropractic manipulation on the pain threshold of myofascial trigger point: a pilot study. Proceedings of: International Conference on Spinal Manipulation 1990:359-363.

Hunter G. Specific soft tissue mobilization in the management of soft tissue dysfunction. Man Ther 1998;3:2-11.

Hyde, T. (2003). Graston technique: a soft tissue treatment for athletic injuries. DC Tracts Fall 2003.

Kasunich NJ. Changes in low back pain in a long distance runner after stretching the iliotibial band. J Chiropr Med 2003;2:37-40.

Kaye MJ. Evaluation and treatment of a patient with upper quarter myofascial pain syndrome. J Sports Chiropr Rehabil 2001;15:26-33.

Leahy P. Improved treatments for carpal tunnel and related syndromes. Chiropr Sports Med 1995;9(1):6-9.

Leahy, PM. Active release techniques: soft tissue management system for the upper extremity. Colorado Springs, CO: Self-published, 1996.

Leahy, PM, Mock LE. Myofascial release technique and mechanical compromise of peripheral nerves of the upper extremity. Chiropr Sports Med 1992;6:139-150.

Melham TJ, Sevier TL et al. Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): a case report. Med Sci in Sports Exer 1998;30(6):801-4.

Mock LE. (1997) Myofascial release treatment of specific muscles of the upper extremity. Part 1. Clin Bull Myofasc Ther 2(1):5-23.1997

Mock LE. (1997) Myofascial release treatment of specific muscles of the upper extremity. Part 2. Clin Bull Myofasc Ther 2(2/3):5-22.1997

Mock LE. (1997) Myofascial release treatment of specific muscles of the upper extremity. Part 3. Clin Bull Myofasc Ther 2(4):51-69.1997

Mock LE. (1998) Myofascial release treatment of specific muscles of the upper extremity. Part 4. Clin Bull Myofasc Ther 3(1):71-93.

Mulcahy R, Johnson J, Witt R. Treatment of myofascial pain utilizing an activator instrument on trigger points. Chiropractic 1994;9:45-46.

Such GW. Manual care of the hyoid complex. Top Clin Chirop 2002;9:54-62. c/r

Walsh MJ, Wise P. Chiropractic treatment of fibromyalgia: two case studies. Chiropr J Aust 2001;31:42-46.

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