1353
ORIGINAL ARTICLE
Effects of Burst-Type Transcutaneous Electrical Nerve
Stimulation on Cervical Range of Motion and Latent
Myofascial Trigger Point Pain Sensitivity
Ángel L. Rodríguez-Fernández, PT, MSc, Víctor Garrido-Santofimia, PT, Javier Güeita-Rodríguez, PT, MSc,
César Fernández-de-las-Peñas, PT, MSc, PhD
ABSTRACT. Rodríguez-Fernández AL, Garrido-Santofimia
V, Güeita-Rodríguez J, Fernández-de-las-Peñas C. Effects of
burst-type transcutaneous electrical nerve stimulation on cer-
vical range of motion and latent myofascial trigger point pain
sensitivity. Arch Phys Med Rehabil 2011;92:1353-8.
Objective: To assess the effects of a burst application of
transcutaneous electrical nerve stimulation (TENS) on cervical
range of motion and pressure point sensitivity of latent myo-
fascial trigger points (MTrPs).
Design: A single-session, single-blind randomized trial.
Setting: General community rehabilitation clinic.
Participants: Individuals (N⫽76; 45 men, 31 women) aged
18 to 41 years (mean ⫾ SD, 23⫾4y) with latent MTrPs in 1
upper trapezius muscle.
Interventions: Subjects were randomly divided into 2 groups:
a TENS group that received a burst-type TENS (pulse width,
200␮s; frequency, 100Hz; burst frequency, 2Hz) stimulation
over the upper trapezius for 10 minutes, and a placebo group
that received a sham-TENS application over the upper trape-
zius also for 10 minutes.
Main Outcome Measures: Referred pressure pain threshold
(RPPT) over the MTrP and cervical range of motion in rotation
were assessed before, and 1 and 5 minutes after the interven-
tion by an assessor blinded to subjects’ treatment.
Results: The analysis of covariance revealed a significant
group ⫻ time interaction (P⬍.001) for RPPT: the TENS group
exhibited a greater increase compared with the control group;
however, between-group differences were small at 1 minute
(0.3kg/cm2; 95% confidence interval [CI], 0.1– 0.4) and at 5
minutes (0.6kg/cm2; 95% CI, 0.3– 0.8) after treatment. A sig-
nificant group ⫻ time interaction (P⫽.01) was also found for
cervical rotation in favor of the TENS group. Between-group
differences were also small at 1 minute (2.0°; 95% CI, 1.0 –2.8)
and at 5 minutes (2.7°; 95% CI, 1.7–3.8) after treatment.
Conclusions: A 10-minute application of burst-type TENS
increases in a small but statistically significant manner the
RPPT over upper trapezius latent MTrPs and the ipsilateral
cervical range of motion.
From the Department of Physical Therapy, Faculty of Medicine, CEU-San Pablo
University, Madrid (Rodríguez-Fernández, Garrido-Santofimia, Güeita-Rodríguez);
and Department of Physical Therapy, Occupational Therapy, Rehabilitation and
Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid (Güeita-
Rodríguez, Fernández-de-las-Peñas), Spain.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Ángel L. Rodríguez-Fernández, PT, MSc, Department of
Physical Therapy, CEU-San Pablo University, Carretera Boadilla del Monte, Km
5,300, Urbanización Montepríncipe, 28668 Boadilla del Monte, Madrid, Spain, e-
mail: alrodfer@ceu.es.
0003-9993/11/9209-00003$36.00/0
doi:10.1016/j.apmr.2011.04.010
Key Words: Cervical spine; Myofascial trigger point; Neck;
Pain threshold; Rehabilitation; Transcutaneous electrical nerve
stimulation.
© 2011 by the American Congress of Rehabilitation
Medicine
M YOFASCIAL PAIN SYNDROME (MPS) is one of the
1
most frequent causes of muscle pain. MPS is character-
ized by the presence of a myofascial trigger point (MTrP),
defined as a hypersensitive spot in a taut band of a skeletal
muscle that is painful to stimulation (compression, or nee-
dling), elicits a referred pain distant to the spot, and is associ-
ated with restricted range of motion.1 From a clinical point of
view, clinicians distinguish between active and latent MTrPs.
An active MTrP causes spontaneous pain, which can be local
and/or referred, and musculoskeletal dysfunction. A latent
MTrP does not cause spontaneous pain but may cause local
and/or referred pain with palpation, and musculoskeletal dys-
function. The main difference between active and latent MTrPs
is the presence of spontaneous pain symptoms; however, both
types of MTrPs induce musculoskeletal dysfunctions.2,3 This
clinical distinction is substantiated by biochemical findings,
since higher levels of algogenic substances and chemical me-
diators, such as bradykinin, substance P, or serotonin, were
found in active MTrPs as compared with latent MTrPs.4,5
Different studies reported that active MTrPs reproduce clin-
ical pain features in several musculoskeletal pain conditions
such as neck pain,6 lateral epicondylalgia,7 shoulder pain,8 or
headaches.9 Conversely, there are an increasing number of
studies demonstrating the clinical and neurophysiologic rele-
vance of latent MTrPs. Ge et al10 found pressure pain hyper-
sensitivity at latent MTrPs as compared with non-MTrP areas,
suggesting nociceptive activity at latent MTrPs. A recent study
confirmed the presence of nociception in latent MTrPs, report-
ing the presence of nociceptive (hyperalgesia) and nonnocice-
ptive (allodynia) pain sensitivity at latent MTrPs.11 Zhang et
al12 reported that nociceptive stimulation of latent MTrPs in-
duces attenuated skin blood flow responses, which suggests a
sympathetic activity elicited by their nociceptive stimulation.
Finally, it has recently been demonstrated that mechanical
stimulation of latent MTrPs can induce central sensitization
mechanisms in healthy subjects.13
List of Abbreviations
ANCOVA analysis of covariance
CI confidence interval
ICC intraclass correlation coefficient
MPS myofascial pain syndrome
MTrP myofascial trigger point
RPPT referred pressure pain threshold
TENS transcutaneous electrical nerve stimulation
Arch Phys Med Rehabil Vol 92, September 2011
1354 BURST-TYPE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION, Rodríguez-Fernández
These findings explain why several studies have investigated
treating subjects with latent MTrPs with different manual tech-
niques.14-19 Among the different approaches used for MTrP
treatment,20 some electrotherapeutic modalities such as inter-
ferential currents,21 magnetic stimulation,22 laser therapy,23
and ultrasound therapy24 are the most common. A recent sys-
tematic review25 found moderate evidence that transcutaneous
electrical nerve stimulation (TENS) is effective in providing
immediate relief of MTrPs.
Various types of TENS have been used for treatment of
upper trapezius MTrPs, with sessions usually lasting 20 min-
utes.26-29 However, we were unable to locate any study in
which the treatment was a burst-type TENS for a period of less
than 20 minutes for the treatment of latent MTrPs. Therefore,
the aim of this study was to investigate the effects of a burst
application of TENS on cervical range of motion and pressure
point sensitivity of latent MTrPs in the upper trapezius muscle.
METHODS
Participants
Seventy-six volunteers (45 men, 31 women) aged 18 to 41
years (mean ⫾ SD, 23⫾4y), recruited from a pain-free popu-
lation by advertisement in the local press in Madrid, Spain,
participated in the current study. Subjects were included if
there was a diagnosis of 1 latent MTrP in either their right or
left upper trapezius. MTrP diagnosis was performed by a
physical therapist with 9 years of experience in MTrP diagnosis
and treatment, and the diagnosis was based on the following
previously published guidelines1: (1) the presence of a palpable
taut band in a skeletal muscle; (2) the presence of a hypersen-
sitive tender spot in the taut band; (3) a local twitch response
provoked by snapping palpation of the taut band; and (4)
reproduction of referred pain in response to compression.
These criteria have exhibited good interexaminer reliability (␬,
.84 –.88) when applied by an experienced examiner.30
Subjects were excluded if they had a history of neck trauma;
surgery in the head-neck area; chronic neck or facial pain; a
history of diagnosed headache, including migraine; MTrP ther-
apy in the neck within the previous 3 months; or fibromyal-
gia.31
This study was approved by the ethical committee of the
CEU-San Pablo University, and all subjects signed an informed
consent before data collection.
Interventions
Participants were randomly divided into 2 groups by coin
toss: a TENS group that received a verum electrotherapy treat-
ment, and a placebo group that received a sham treatment.
For the TENS group, a burst-TENS with a pulse width of
200␮s, a pulse frequency of 100Hz, and a burst frequency of
2Hz was applied for 10 minutes at a comfortable intensity able
to induce contraction of the upper trapezius muscle.32 This was
done using a BTL 5000a electrical stimulation device. The
active electrode (size, 3.2cm2) was placed over the MTrP,
whereas the ground electrode (size, 24cm2) was placed over the
deltoid insertion.
The placebo group received a sham-electrotherapy TENS
application also for 10 minutes. Electrodes were placed in the
same position as in the TENS group. Subjects were informed
that they would receive an electric current at a subliminal level.
The electrical stimulator was switched on during the applica-
tion with an intensity of zero. Subjects were not able to see the
device screen so that the intensity rating was masked, and
every effort was made to ensure they believed they were
receiving the electrical application (blinding patient).
Arch Phys Med Rehabil Vol 92, September 2011
Outcome Measures
In the current study, outcomes included neck rotation as
measured by a digital goniometer,b and referred pressure pain
threshold (RPPT) with a mechanical pressure algometer.c
For cervical rotation, subjects were supine. The reference
position was 90° to the horizontal. The free arm of the goni-
ometer was in alignment with the patient’s nose. Active rota-
tion was performed until the contralateral shoulder began to
rise from the table. The free arm of the goniometer was then
positioned in the new alignment of the nose. Cervical rotation
was calculated as the difference between the initial and final
values recorded.33 Three measurements at intervals of 30 sec-
onds were obtained by the same assessor, and the mean was
calculated for the main analysis. We calculated intraexaminer
reliability of cervical rotation with an intraclass correlation
coefficient (ICC) by using a 2-way random effects model.34 We
found good reliability for ipsilateral (ICC⫽.73; 95% confi-
dence interval [CI], .60 –.84) and contralateral (ICC⫽.75; 95%
CI, .62–.85) rotations.
The RPPT is defined as the pressure that begins to elicit the
referred pain when applied over an MTrP.35 Three consecutive
trials of RPPT on the MTrP at intervals of 30 seconds were
obtained by the same assessor, and the mean was calculated for
the main analysis. Ylinen et al36 found good intraexaminer
reliability for assessing pressure pain thresholds over MTrPs in
the upper trapezius muscle (ICC⫽.86; 95% CI, .67–.74). In the
current study, intrarater reliability of RPPT was also calculated
with an ICC,34 and we found high reliability (ICC⫽.90; 95%
CI, .85–.93) for our data.
Both outcomes were assessed before the intervention, and at
1 and 5 minutes after the intervention by an assessor blinded to
the subject’s treatment.
Statistical Analysis
Sample size calculation was based on results reported by
Ruiz-Sáez et al18 and was performed with a local software.d
The calculations were based on detecting a 20% of within-
group differences in RPPT after the intervention compared
with before treatment, assuming an SD of 10%, an ␣ level of
.05, and a desired power (␤) of 80%. These assumptions
generated a sample size of at least 30 participants per group.
Data were analyzed with SPSS version 15.0.e Mean, SD, and
95% CI for each variable were calculated. A normal distribu-
tion of quantitative data was assessed by the Kolmogorov-
Smirnov test (P⬎.05). Baseline data between groups were
compared using chi-square tests of independence for categor-
ical data and independent Student t tests for continuous data. A
repeated-measure analysis of covariance (ANCOVA) with time
(before, 1 and 5min after treatment) as within-subjects factor,
group (verum or sham TENS) as between-subject factor, and
age and sex as covariables was used to assess differences in
RPPT. A repeated-measure ANCOVA with time (before, 1 and
5min after treatment) and side (ipsilateral or contralateral) as
within-subjects factors, group (verum or sham TENS) as between-
subjects factor, and age and sex as covariables was used to analyze
differences in cervical rotation. The main hypothesis of interest
was group ⫻ time interaction. Within-group and between-group
effect sizes were calculated using Cohen’s d coefficient.37 An
effect size of less than 0.2 reflects a negligible mean difference;
between ⱖ0.2 and ⱕ0.5, a small difference; between ⱖ0.5 and
ⱕ0.8, a moderate mean difference; and 0.8 or greater, a large
difference. The statistical analysis was conducted at a 95% con-
fidence level, and a P value of less than .05 was considered as
statistically significant.
 BURST-TYPE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION, Rodríguez-Fernández
RESULTS
One hundred volunteers were screened for eligible criteria.
Twenty four (24%) were excluded because of no latent MTrP
in 1 upper trapezius (n⫽12), previous neck trauma (n⫽8), and
a history of migraine (n⫽4). Finally, 38 subjects (22 men, 16
women; mean age ⫾ SD, 22⫾3y) were assigned to the TENS
group, and the remaining 38 (23 men, 15 women; mean age ⫾
SD, 24⫾5y) were assigned to the placebo group. The total
number of subjects screened, reasons for ineligibility, and
dropouts can be seen in figure 1. No significant differences for
sex (␹2⫽.054, P⫽.815), RPPT (t⫽.492, P⫽.624), and cervical
rotation (ipsilateral to the MTrP: t⫽.161, P⫽.872; contralateral
to the MTrP: t⫽.244, P⫽.808) were found, indicating that
groups were comparable in all dependent measures at the start
of the study (table 1). However, participants in the sham-TENS
group were older (t⫽– 2.277, P⫽.026) than those included in
the real-TENS group. Because of this, age was included in the
analysis as a covariate.
All participants showed latent MTrPs in 1 upper trapezius
muscle, of which 58 (76%) were located in the right side
(dominant side) and 18 (24%) within the left side (nondomi-
nant). No significant differences for the distribution of latent
MTrPs in the upper trapezius muscles (␹2⫽1.235, P⫽.634)
were found between groups.
Referred Pressure Pain Thresholds
The ANCOVA revealed a significant group ⫻ time interac-
tion (F⫽24.932, P⬍.001) for changes in RPPT over upper
trapezius latent MTrPs: the real-TENS group exhibited a
greater increase in RPPT as compared with the sham-TENS
group (P⬍.001). Neither age (F⫽.900, P⫽.346) nor sex
(F⫽.186, P⫽.660) affected the results. Within-group (pre-post)
effect sizes were large (d⫽0.9) for the TENS group and neg-
ligible (d⫽0) for the sham-TENS group. However, between-
group differences were small at 1 minute (0.3kg/cm2; 95% CI,
0.1– 0.4) and at 5 minutes (0.6kg/cm2; 95% CI, 0.3– 0.8) after
treatment. Tables 2 and 3 summarize the data before treatment
and at 1 and 5 minutes after treatment, as well as the within-
and between-group differences for RPPT over upper trapezius
latent MTrPs in both groups.
Fig 1. Flow diagram of subject recruitment throughout the course
of the study.
1355
Table 1: Baseline Demographics for Both Groups
Real-TENS Sham-TENS
Characteristic Group Group P
Sex (M/F) 22/16 23/15 .815
Age (y)* 22⫾3 24⫾5 .026
RPPT (kg/cm2) 2.1⫾0.5 2.2⫾0.8 .624
Cervical rotation ipsilateral to
the MTrP (deg) 57.9⫾5.4 57.7⫾5.9 .872
Cervical rotation contralateral
to the MTrP (deg) 58.2⫾6.0 58.5⫾6.1 .808
NOTE. Values are n, mean ⫾ SD, or as otherwise indicated.
Abbreviations: F, female; M, male.
*Statistically significant differences between groups (included in the
ANCOVA as covariate).
Cervical Rotation
The ANCOVA revealed a significant group ⫻ time interac-
tion (F⫽6.894, P⫽.01) for changes in cervical rotation: the
TENS group exhibited a greater increase in rotation as com-
pared with the sham-TENS group (P⬍.05). Neither age
(F⫽2.966, P⫽.148) nor sex (F⫽2.095, P⫽.181) affected the
results. Within-group effect sizes were small (d⫽.36) for both
rotations within the real-TENS group and negligible (d⫽.11)
for the placebo group. In addition, between-group differences
were also small at 1 minute (2.0°; 95% CI, 1.0 –2.8) and at 5
minutes (2.7°; 95% CI, 1.7–3.8) after treatment. Tables 2 and
3 detail the data before treatment and at 1 and 5 minutes after
treatment, and the within- and between-group differences for
cervical rotation in both groups.
DISCUSSION
The results of the current study suggest that a single appli-
cation of a burst-type TENS had an immediate mild hypoalge-
sic effect for mechanical stimuli by increasing the RPPT over
latent MTrPs in the upper trapezius muscle. We also found that
a burst-type TENS increases cervical rotation ipsilateral to the
side of the MTrP. The changes observed were small, particu-
larly for cervical range of motion (0.3– 0.5kg/cm2 for RPPT;
2.2°–2.9° for ipsilateral rotation), which may indicate limited
clinical relevance.
TENS and RPPT
Some studies investigating changes in pressure pain thresh-
olds after application of mobilization interventions reported
changes around 10%,38,39 values slightly lower than the im-
provements found in our study (15%–30%) for RPPT. Never-
theless, we should recognize that changes found in the current
study are small, so the clinical implications should be ques-
tioned.
Johnson and Martinson,40 in their meta-analysis, determined
that the application of TENS was effective for the treatment of
chronic musculoskeletal pain as compared with placebo. In
addition, a review of noninvasive interventions for the man-
agement of MTrPs concluded that TENS is effective in the
short-term for reducing pain originating in MTrPs.41 This as-
sumption was based on studies where TENS has been found to
be effective in reducing MTrP pain.26,27,42 However, these
studies did not include pressure algometry as a main outcome.
Therefore, the current study is, to our knowledge, the first one
investigating changes in RPPT over latent MTrPs after the
application of burst-TENS. Nevertheless, we should recog-
nize that the inclusion of latent MTrPs limits the clinical
relevance of our results.
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1356 BURST-TYPE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION, Rodríguez-Fernández

Table 2: Baseline, 1 Minute After Intervention, and Change Scores for Referred Pain Thresholds and Cervical Rotation
Before 1min After Within-Group Between-Group
Group Intervention Intervention Change Scores Change Scores

RPPT (kg/cm2)
Real-TENS group 2.1⫾0.5 2.4⫾0.5 0.3 (0.2 to 0.5) 0.3 (0.1–0.4)
Sham-TENS group 2.2⫾0.8 2.2⫾0.7 0.0 (⫺0.2 to 0.1)
Cervical rotation ipsilateral to the MTrP (deg)
Real-TENS group 57.9⫾5.4 59.3⫾4.7 1.4 (0.2 to 2.7) 2.0 (1.0–2.8)
Sham-TENS group 57.7⫾5.9 57.1⫾5.4 ⫺0.6 (⫺1.8 to 0.7)
Cervical rotation contralateral to the MTrP (deg)
Real-TENS group 58.2⫾6.0 58.9⫾6.0 0.7 (0.5 to 1.9) 0.7 (0.1–1.4)
Sham-TENS group 58.5⫾6.1 58.5⫾6.1 0.0 (⫺1.4 to 1.3)

NOTE. Values are mean ⫾ SD or mean (95% CI).

Determining the mechanisms by which TENS may increase
RPPT is beyond the scope of this study; however, a few
hypotheses can be proposed. It appears that TENS could influ-
ence some of the events related to MTrP pathogenesis. Con-
tractions induced by the burst-TENS could normalize endplate
acetylcholine secretion and reduce algogenic substances found
within the MTrP area.5 In addition, muscle contractions
(twitches) induced by TENS may increase local blood flow of
the MTrP area, leading to a “washout” of these inflammatory
mediators. Sandberg et al43 reported an increase of blood flow
in the muscle after the application of a burst-TENS (pulse
width, 180␮s; burst frequency, 2Hz) for 15 minutes. Kavcic et
al44 found that application of a burst-TENS for 20 minutes
produced an increase in muscle oxygenation within the upper
trapezius muscle. Therefore, it is possible that application of a
burst-TENS may increase blood flow and remove the chemical
mediators of the MTrP area, thereby facilitating a mechanical
relaxation of the MTrP taut band.
Another possible mechanism may involve central nervous
system effects.45 The burst-type TENS can increase RPPT over
MTrPs by increasing firing rates at the spinal dorsal horn. Tong
et al46 demonstrated that the use of low-frequency TENS
increased the release of enkephalin and ␤-endorphins. Because
␤-endorphin stimulates the periaqueductal gray substance and
activates inhibitory descending pathways,47 the increase ob-
served in RPPT after application of a burst-TENS may be
related to activation of these inhibitory pain pathways. Future
studies are needed to further explore these mechanisms.
TENS and Cervical Range of Motion
This study also showed that a burst-TENS induced a small
(2.4°–2.9°) increase in cervical rotation, particularly to the
ipsilateral side of the MTrP, as compared with sham-TENS.
Cervical rotation was chosen to minimize the measurement
errors when using a universal goniometer. An increase in
cervical rotation ipsilateral to the MTrP suggests that burst-
TENS may induce a relaxation of the MTrP taut band accord-
ing to the mechanisms mentioned above. Our results are similar
to those reported for the application of high-power ultrasound24
or TENS plus stretching28 over the MTrP within the upper
trapezius, where an increase in cervical lateral flexions was
observed. Interestingly, an increase in cervical rotation ipsilat-
eral to the MTrP was unexpected because relaxation of the
upper trapezius should improve cervical rotation contralateral
to the MTrP. One possible explanation is that burst-TENS
application may induce relaxation of the MTrP taut band and
facilitate the stretching (in ipsilateral rotation) of the upper
trapezius. We should recognize that the effect sizes were small,
and these results should be considered with caution and of
dubious clinical relevance.
Study Limitations
First, we only assessed the immediate hypoalgesic effects
over latent MTrPs and cervical rotation after the application of
a single treatment with burst-TENS. It would be interesting to
investigate long-term effects of TENS to further explore the
mechanisms behind the observed benefits. Second, we do not
know whether these hypoalgesic effects are widespread involv-
ing MTrPs in other distant anatomic areas. The immediate
changes that occurred after burst-TENS application provide
impetus for further studies in this area. A third limitation is that
we included only participants with latent MTrPs, and they may
not be the typical population presenting to therapists for treat-
ment. This situation may provoke the difficulty for assessing
clinical benefit of the treatment. Fourth, it is necessary to
investigate changes in all cervical movements after the appli-

Table 3: Baseline, 5 Minutes After Intervention, and Change Scores for Referred Pain Thresholds and Cervical Rotation
Before 5min After Within-Group Between-Group
Group Intervention Intervention Change Scores Change Scores

RPPT (kg/cm2)
Real-TENS group 2.1⫾0.5 2.7⫾0.8 0.6 (0.4 to 0.8) 0.6 (0.3–0.8)
Sham-TENS group 2.2⫾0.8 2.2⫾0.8 0.0 (⫺0.2 to 0.2)
Cervical rotation ipsilateral to the MTrP (deg)
Real-TENS group 57.9⫾5.4 59.7⫾4.6 1.8 (0.5 to 3.1) 2.7 (1.7–3.8)
Sham-TENS group 57.7⫾5.9 56.8⫾5.6 ⫺0.9 (⫺2.3 to 0.7)
Cervical rotation contralateral to the MTrP (deg)
Real-TENS group 58.2⫾6.0 58.9⫾6.5 0.7 (0.6 to 1.8) 1.1 (0.2–2.0)
Sham-TENS group 58.5⫾6.1 58.1⫾6.2 ⫺0.4 (⫺2.1 to 1.2)

NOTE. Values are mean ⫾ SD or mean (95% CI).

Arch Phys Med Rehabil Vol 92, September 2011

 BURST-TYPE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION, Rodríguez-Fernández
cation of burst-TENS. Finally, we recognize that the duration
of the burst-TENS application (10min) was shorter than stan-
dard applications (15–20min). This shorter duration was based
on our clinical experience. Because the current study found that
10 minutes had some potential effects on MTrP mechanical
sensitivity, future studies should compare the effects of burst-
TENS depending on the duration of application.
CONCLUSIONS
An application of a burst-type TENS had mild hypoalgesic
effects for mechanical stimuli by increasing RPPT over latent
MTrPs in the upper trapezius muscle. Burst-type TENS also
increased cervical rotation ipsilateral to the side of the MTrP.
The observed changes were relatively small (0.3– 0.5kg/cm2
for RPPT; 2.2°–2.9° for ipsilateral rotation), potentially indi-
cating limited clinical relevance.
References
1. Simons DG, Travell JG, Simons LS. Myofascial pain and dys-
function. The trigger point manual. Vol 1. 2nd ed. Baltimore:
Williams & Wilkins; 1999.
2. Lucas KR, Polus BI, Rich PA. Latent myofascial trigger points:
their effects on muscle activation and movement efficiency. J
Bodywork Mov Ther 2004;8:160-6.
3. Lucas KR. The impact of latent trigger points on regional muscle
function. Curr Pain Headache Rep 2008;12:344-9.
4. Shah JP, Phillips TM, Danoff JV, Gerber L. An in vivo microan-
alytical technique for measuring the local biochemical milieu of
human skeletal muscle. J Appl Physiol 2005;99:1977-84.
5. Shah JP, Gilliams EA. Uncovering the biochemical milieu of
myofascial trigger points using in vivo microdialysis: an applica-
tion of muscle pain concepts to myofascial pain syndrome. J
Bodyw Mov Ther 2008;12:371-84.
6. Fernández-de-las-Peñas C, Alonso-Blanco C, Miangolarra J.
Myofascial trigger points in subjects presenting with mechanical
neck pain: a blinded, controlled study. Man Ther 2007;12:29-33.
7. Fernández-Carnero J, Fernández-de-las-Peñas C, De-la-Llave-
Rincón AI, Ge HY, Arendt-Nielsen L. Prevalence of and referred
pain from myofascial trigger points in the forearm muscles in
patients with lateral epicondylalgia. Clin J Pain 2007;23:353-60.
8. Hidalgo-Lozano A, Fernández-de-las-Peñas C, Alonso-Blanco C,
Ge HY, Nielsen A, Arroyo-Morales M. Muscle trigger points and
pressure pain hyperalgesia in the shoulder muscles in patients with
unilateral shoulder impingement: a blinded, controlled study. Exp
Brain Res 2010;202:915-25.
9. Fernández-de-las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Si-
mons DG, Pareja JA. Myofascial trigger points and sensitisation:
an updated pain model for tension type headache. Cephalalgia
2007;27:383-93.
10. Ge HY, Fernández-de-las-Peñas C, Arendt-Nielsen L. Sympa-
thetic facilitation of hyperalgesia evoked from myofascial tender
and trigger points in patients with unilateral shoulder pain. Clin
Neurophysiol 2006;117:1545-50.
11. Li LT, Ge HY, Yue SW, Arendt-Nielsen L. Nociceptive and
non-nociceptive hypersensitivity at latent myofascial trigger
points. Clin J Pain 2009;25:132-7.
12. Zhang Y, Ge HY, Yue SW, Kimura Y, Arendt-Nielsen L. Atten-
uated skin blood flow response to nociceptive stimulation of latent
myofascial trigger points. Arch Phys Med Rehabil 2009;90:
325-32.
13. Xu YM, Ge HY, Arendt-Nielsen L. Sustained nociceptive me-
chanical stimulation of latent myofascial trigger point induces
central sensitization in healthy subjects. J Pain 2010;11:1348-55.
14. Fryer G, Hodgson L. The effect of manual pressure release on
myofascial trigger points in the upper trapezius muscle. J Bodyw
Mov Ther 2005;9:248-55.
1357
15. Montañez FJ, Pecos D, Arnau R, Camps A, Borja L, Bosch F.
Immediate effect of ultrasound and ischemic compression tech-
niques for the treatment of trapezius latent myofascial trigger
points in healthy subjects: a randomized controlled study. J Ma-
nipulative Physiol Ther 2009;32:515-20.
16. Ibáñez-García J, Alburquerque-Sendín F, Rodríguez-Blanco C, et
al. Changes in masseter muscle trigger points following strain/
counter-strain or neuro-muscular technique. J Bodyw Mov Ther
2009;13:2-10.
17. Rodríguez-Blanco C, Fernández-de-las-Peñas C, Hernández-
Xumet JE, Peña-Algaba G, Fernández-Rabadán M, Lillo MC.
Changes in active mouth opening following a single treatment of
latent myofascial trigger points in the masseter muscle involving
post-isometric relaxation or strain/counter-strain. J Bodyw Mov
Ther 2006;10:197-205.
18. Ruiz-Sáez M, Fernández-de-las-Peñas C, Rodríguez-Blanco C,
Martínez-Segura R, García-León R. Changes in pressure pain
sensitivity in latent myofascial trigger points in the upper trapezius
muscle following a cervical spine manipulation in pain-free sub-
jects. J Manipulative Physiol Ther 2007;30:578-83.
19. Oliveria-Campelo N, Rubens-Rebelatto J, Martín-Vallejo FJ, Al-
burquerque-Sendín F, Fernández-de-las-Peñas C. The immediate
effects of atlanto-occipital joint manipulation and suboccipital
muscle inhibition technique on active mouth opening and pressure
pain sensitivity over latent myofascial trigger points in the mas-
ticatory muscles. J Orthop Sports Phys Ther 2010;40:310-7.
20. Dommerholt J, Bron C, Franssen JL. Myofascial trigger points: an
evidence informed review. J Man Manip Ther 2006;14:203-21.
21. Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate
effects of various physical therapeutic modalities on cervical
myofascial pain and trigger-point sensitivity. Arch Phys Med
Rehabil 2002;83:1406-14.
22. Smania N, Corato E, Fiaschi A, Pietropoli P, Aglioty SM, Tinazzi
M. Therapeutic effects of peripheral repetitive magnetic stimula-
tion on myofascial pain syndrome. Clin Neurophysiol 2003;114:
350-8.
23. Gur A, Sarac AJ, Cevik R, Altindag O, Sarac S. Efficacy of 904
nm gallium arsenide low level laser therapy in the management of
chronic myofascial pain in the neck: a double-blind and random-
ize-controlled trial. Lasers Surg Med 2004;35:229-35.
24. Majlesi J, Ünalan MD. High-power pain threshold ultrasound
technique in the treatment of active myofascial trigger points: a
randomized, double-blind, case-control study. Arch Phys Med
Rehabil 2004;85:833-6.
25. Vernon H, Schneider M. Chiropractic management of myofascial
trigger points and myofascial pain syndrome: a systematic review
of the literature. J Manipulative Physiol Ther 2009;32:14-24.
26. Hsueh TC, Cheng PT, Kuan TS, Hong CZ. The immediate effec-
tiveness of electrical nerve stimulation and electrical muscle stim-
ulation on myofascial trigger points. Am J Phys Med Rehabil
1997;76:471-6.
27. Ardiç F, Sarhus M, Topuz O. Comparison of two different tech-
niques of electrotherapy on myofascial pain. J Back Musculosk-
elet Rehabil 2002;16:11-6.
28. Kavcic NS, Lehman GH, McGill SM. Effect of modulated TENS
on muscle activation, oxygenation, and pain: searching for a
physiological mechanism. J Musculoskel Pain 2005;13:19-30.
29. Farina S, Casarotto M, Benelle M, et al. A randomized controlled
study on the effect of two different treatments (FREMS and
TENS) in myofascial pain syndrome. Eura Medicophys 2004;40:
293-301.
30. Gerwin R, Shannon S, Hong C, Hubbard D, Gevirtz R. Interrater
reliability in myofascial trigger point examination. Pain 1997;69:
65-73.
31. Wolfe F, Smythe HA, Yunus MB, et al. The American College of
Rheumatology 1990 criteria for classification of fibromyalgia:
Arch Phys Med Rehabil Vol 92, September 2011
1358 BURST-TYPE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION, Rodríguez-Fernández
report of the multicenter criteria committee. Arthritis Rheum
1990;33:160-70.
32. Johnson MI. Trans-cutaneous electrical nerve stimulation (TENS).
In: Watson T, editor. Electrotherapy: evidence-based practice.
Philadelphia: Churchill Livingstone; 2008. p 253-96.
33. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of
cervical spine range of motion— comparison of three methods.
Phys Ther 1991;71:98-104.
34. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing
rater reliability. Psychol Bull 1979;86:420-8.
35. Vanderweeen L, Oostendorp RB, Vaes P, Duquet W. Pressure
algometry in manual therapy. Man Ther 1996;1:258-65.
36. Ylinen J, Nykanen M, Kautainen H, Hakkinen A. Evaluation of
repeatability of pressure algometry on the neck muscles for clin-
ical use. Man Ther 2007;12:192-7.
37. Cohen J. Statistical power analysis for the behavioural sciences
Hillsdale: Lawrence Erlbaum Associates; 1988.
38. Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific
manipulative therapy treatment for chronic lateral epicondylalgia
produces uniquely characteristic hypoalgesia. Man Ther 2001;6:
205-12.
39. Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgesic
and sympatho-excitatory effects of mobilization with movement
for lateral epicondylalgia. Phys Ther 2003;83:374-83.
40. Johnson M, Martinson M. Efficacy of electrical nerve stimulation
for chronic musculoskeletal pain: a meta-analysis of randomized
controlled trials. Pain 2007;130:157-65.
41. Rickards LD. The effectiveness of non-invasive treatments for
active myofascial trigger point pain: a systematic review of the
literature. Int J Osteopath Med 2006;9:120-36.
Arch Phys Med Rehabil Vol 92, September 2011
42. Graff-Radford SB, Reeves JL, Baker R, Chiu D. Effects of trans-
cutaneous electrical nerve stimulation on myofascial pain and
trigger point sensitivity. Pain 1989;37:1-5.
43. Sandberg ML, Sandberg MK, Dahl J. Blood flow changes in the
trapezius muscle and overlaying skin following trans-cutaneous
electrical nerve stimulation. Phys Ther 2007;87:1047-55.
44. Kavcic NS, Lehman GH, McGill SM. Effect of modulated TENS
on muscle activation, oxygenation, and pain: searching for a
physiological mechanism. J Musculoskel Pain 2005;13:19-30.
45. Somers DL, Clemente R. Contra-lateral high or a combination of
high- and low-frequency trans-cutaneous electrical nerve stimula-
tion reduces mechanical allodynia and alters dorsal horn neu-
rotransmitter content in neuropathic rats. J Pain 2009;10:221-9.
46. Tong KC, Lo SK, Cheing GL. Alternating frequencies of trans-
cutaneous electric nerve stimulation: does it produce greater an-
algesic effects on mechanical and thermal pain thresholds? Arch
Phys Med Rehabil 2007;88:1344-9.
47. Brown JH. Stimulation-produced analgesia: acupuncture, TENS
and alternative techniques. Anaesth Intensive Care Med 2005;6:
45-7.
Suppliers
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