Myofascial Findings and Psychopathological Factors in Patients with Chronic Pelvic Pain Syndrome.

OBJECTIVE: Chronic pelvic pain syndrome (CPPS) is a common pain condition with psychosocial and somatic symptoms. Myofascial findings and psychiatric comorbidities are frequent. Therefore, the aim of the study was to analyze myofascial and psychosocial aspects. Furthermore, the study focuses on correlations between these aspects and gender differences in this topic. DESIGN: Cross-sectional study. SETTING: Interdisciplinary outpatient clinic for patients with CPPS at the University Medical Centre Hamburg-Eppendorf, Germany. METHODS: Participants underwent a multimodal diagnostic algorithm including physiotherapeutic assessment and psychotherapeutic evaluation. Those with a positive diagnosis of CPPS were included. Descriptive statistics were used to characterize and analyze the sample. Bivariate correlations were calculated for the association between myofascial findings and psychopathological symptoms. RESULTS: A total of 187 patients (56.7% female, mean age ± SD = 49.06 ± 17.05 years) were included. Women had significantly higher numbers of tender (mean ± SD = 17.53 ± 9.58 vs 13.40 ± 8.79, P = 0.003) and trigger points (mean ± SD = 6.23 ± 6.64 vs 4.09 ± 7.15, P = 0.036). They had also significantly higher values in the PHQ-15 (mean ± SD = 11.51 ± 5.24 vs 9.28 ± 5.49, P = 0.009) and the SF-MPQ (mean ± SD = 17.84 ± 8.95 vs 15.11 ± 7.97, P = 0.041). Several significant correlations between myofascial findings and psychosocial factors exist. CONCLUSIONS: There might be a link between psychosomatic and myofascial aspects in CPPS; thus further studies are needed. Nevertheless, the results stress the urgent need of a multimodal treatment including physiotherapy and psychotherapy in these patients.

A self-determination theory-based self-myofascial release program in older adults with myofascial trigger points in the neck and back: A pilot study.

PURPOSE: To examine the effectiveness and adherence to a self-determination theory (SDT)-based self-myofascial release (SMR) program in older adults with myofascial trigger points (MTrPs), and to investigate the factors that influence participant behavioral change while conducting the program in a home setting. METHODS: An explanatory mixed-method design was used to evaluate a 12-week SDT-based SMR program, including a 4-week group-based education and practice (EP) phase and an 8-week home-based self-management (SM) phase. Pain intensity on palpation and sensitivity to pain were assessed at baseline and the post EP and post SM phase. Focus group interviews were conducted at the post SM phase. FINDINGS: Fifteen participants completed the study. Pain intensity and sensitivity to pain significantly improved at the post SM phase compared with the baseline. Adherence increased during the SM phase compared with that during the EP phase. Four main themes emerged as factors that influenced participant behavioral change: 1) "awareness of the effectiveness"; 2) "a sense of duty to perform the exercise"; 3) "obedience to expert instruction"; and 4) "lack of friendship." CONCLUSIONS: These results support the effectiveness of an SDT-based SMR program for the treatment of MTrPs and in motivating older adults to participate in the program.

Comparision of two different dry-needling techniques in the treatment of myofascial pain syndrome.

OBJECTIVES: To compare the efficacy of two different dry needling (DN) techniques (deep dry needling & peppering) in myofascial pain syndrome (MPS). METHODS: Seventy-two patients, who were diagnosed as MPS at our outpatient clinic were randomly assigned into two groups as deep dry needling (DDN) and peppering. All patients were evaluated four times as: before the treatment and 1-5-12 weeks after the completion of treatment protocol. In each evaluation, Visual analogue scale (VAS), Nottingham extended activities of daily living scale (NEADLS), Beck depression inventory (BDI) scores were recorded. Additionally, all patients were evaluated for the pain felt during the procedure and side effect profile. RESULTS: Twenty-six patients from DDN group and twenty-eight patients from peppering group accomplished the follow-up period. Both DDN and peppering seem to be effective for relieving pain and depressive symptoms and improving functionality compared to baseline when evaluated on the 1st, 5th and 12th weeks. On the other hand the intergroup analyses showed no significant differences between DDN and peppering groups. The only significant difference between the groups is the lesser pain felt during the procedure in the DDN group. CONCLUSION: Both DDN and peppering are effective in MPS and the effects last up to 12 weeks. Also the adverse event profiles of the two techniques are similar. On the other hand, DDN is a painless procedure.

Change in Health-Related Quality-of-Life at Group and Individual Levels Over Time in Patients Treated for Chronic Myofascial Neck Pain.

BACKGROUND: This study evaluated change in health-related quality of life at the group and individual levels in a consecutive series of patients with chronic myofascial neck pain. METHODS: Fifty patients with chronic neck pain self-administered the Short Form-36 Version 2 (SF-36 v2) before treatment and 6 weeks later. Internal consistency reliability was estimated for the 8 scale scores and Mosier's formula was used to estimate reliability of the physical and mental health composite scores. Significance of group-level change was estimated using within-group t statistics. Significance of individual change was evaluated by reliable change index. RESULTS: Statistically significant ( P < .05) group mean improvement over time was found for all SF-36 scores. At the individual level, 20% of the possible changes were statistically significant (17% improvement, 3% decline). CONCLUSIONS: Estimating the significance of individual change in health-related quality of life adds important information in comparing different treatment modalities for chronic myofascial neck pain.

Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach.

BACKGROUND: This study comprehensively evaluated a myofascial triggerpoint release (MTR) technique for shoulder pain. METHODS: Twenty-three (from an initial sample of 25) patients experiencing shoulder pain received MTR, in four 10-min sessions over a period of 2 weeks, applied exclusively on the more painful shoulder, with assessments being recorded both before and after treatment (and for pain at 1 and 13 months). Measures of stiffness and elasticity were collected to monitor the process of therapy, while subjective measures of pain and objective measures of pressure pain thresholds tracked primary outcomes. Secondary outcomes focused on suffering, stress, and quality of life. RESULTS: A statistically significant decrease in stiffness and increase in elasticity was observed post intervention for the treated side only, while pressure pain thresholds improved on the untreated side as well. Reports of pain significantly decreased after treatment, with gains being maintained at 1 and 13 months following treatment. Levels of suffering, stress, and quality of life revealed statistically significant improvement as well. CONCLUSIONS: MTR resulted in clinically significant improvements in the primary measures of pain, objective mechanical tissue properties, and secondary measures in patients with chronic shoulder pain.

Pretreatment anxiety and pain acceptance are associated with response to trigger point injection therapy for chronic myofascial pain.

BACKGROUND AND AIM: This study examined the psychosocial profile of patients who responded or did not respond to trigger point injection therapy for chronic myofascial pain. METHODS: Seventy one patients with a diagnosis of chronic myofascial pain of the paraspinous muscles completed a pretreatment questionnaire measuring demographic and social factors, and validated scales to assess pain intensity, pain interference (physical and emotional), and defined psychological characteristics (pain catastrophizing, pain acceptance, pain self-efficacy, mood and anxiety). Trigger point injection therapy of the affected areas of myofascial pain was performed and follow-up was conducted by telephone at one week (n = 65) and one month (n = 63) post intervention to assess treatment outcome (pain intensity and pain-related physical interference). RESULTS: At one week follow-up and one-month follow-up, using pain-related physical interference as the outcome measure, we found that those who responded well to treatment were characterized by a lower level of pretreatment anxiety and a higher level of pain acceptance, with anxiety being the strongest predictor. CONCLUSION: These results suggest that responses to interventional pain management in chronic myofascial paraspinous pain may be influenced by psychological characteristics, especially pretreatment anxiety.

Botulinum toxin type a injections for cervical and shoulder girdle myofascial pain using an enriched protocol design.

BACKGROUND: Myofascial pain syndrome is a regional condition of muscle pain and stiffness and is classically characterized by the presence of trigger points in affected musculature. Botulinum toxin type A (BoNT-A) has been shown to have antinociceptive properties and elicit sustained muscle relaxation, thereby possibly affording even greater relief than traditional strategies. Our goal was to determine whether direct injection of BoNT-A into painful muscle groups is effective for cervical and shoulder girdle myofascial pain. METHODS: An enriched protocol design was used, wherein 114 patients with cervical and shoulder girdle myofascial pain underwent injection of BoNT-A to determine their response to the drug. Fifty-four responders were then enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. Pain scales and quality of life measures were assessed at baseline and at routine follow-up visits until completion of the study after 26 weeks. RESULTS: Injection of BoNT-A into painful muscle groups improved average visual numerical pain scores in subjects who received a second dose of BoNT-A compared to placebo (P = 0.019 [0.26, 2.78]). Subjects who received a second dose of BoNT-A had a reduced number of headaches per week (P = 0.04 [0.07, 4.55]). Brief Pain Inventory interference scores for general activity and sleep were improved (P = 0.046 [0.038, 3.700] and 0.02 [0.37, 4.33], respectively) in those who received a second dose of BoNT-A. CONCLUSION: BoNT-A injected directly into painful muscle groups improves average pain scores and certain aspects of quality of life in patients experiencing severe cervical and shoulder girdle myofascial pain.

An update on botulinum toxin A injections of trigger points for myofascial pain.

Myofascial pain syndrome (MPS) is a common chronic pain condition that is characterized by distinct "trigger points." Despite current treatments with physical therapy, analgesics, anti-depressants and trigger-point injections, myofascial pain remains a challenging chronic pain condition in clinical practice. Botulinum toxin A (BTX-A) can cause prolonged muscle relaxation through inhibition of acetylcholine release. It may offer some advantages over the current treatments for MPS by providing a longer sustained period of pain relief. Despite numerous clinical trials, the efficacy of BTX-A in alleviating MPS is not well-established due to mixed results from recent clinical trials. Active trigger points are associated with referred pain and greatly impact many aspects of activities of daily living, mood, and health status. This review is designed to analyze the clinical trials regarding the efficacy of BTX-A injection of active trigger points as a treatment for MPS. The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline and EMbase. Our search terms included "Botulinum toxin," "myofascial pain," "trigger points," "myofascial trigger points," "chronic pain." Additional references were retrieved from the reference list of the reports found via this search. Studies were considered eligible for inclusion if they were double-blinded, randomized, controlled trials evaluating the efficacy of BTX-A injections into trigger points for pain reduction, and if the trigger point selection in the trial included referred pain and/or local twitch response. Open-label studies, case reports, and other non-randomized studies were excluded. Eight trials were found according to the above criteria and are summarized in Table 1. There are well-designed clinical trials to support the efficacy of trigger-point injections with BTX-A for MPS. However, further clinical trials with considerations of minimizing placebo effect, repeated dosing, adequate coverage of trigger points, and using ultrasound confirmation and guidance are required to provide conclusive evidence for BTX-A in the treatment of myofascial pain.

[Fibromyalgia syndrome as a psychosomatic disorder - diagnosis and therapy according to current evidence-based guidelines]. / Das Fibromyalgiesyndrom als psychosomatische Erkrankung - empfehlungen Aktueller Evidenzbasierter Leitlinien zu Diagnostik und Therapie.

OBJECTIVES: The classification and therapy of patients with chronic widespread pain without evidence of somatic factors as an explanation is currently a matter of debate. The diagnostic label "fibromyalgia syndrome"(FMS) has been rejected by some representatives of general and psychosomatic medicine. METHODS: A summary is given of the main recommendations from current evidence-based guidelines on FMS and nonspecific/functional/somatoform bodily complaints. RESULTS: The criteria of FMS and of persistent somatoform pain disorder or chronic pain disorder with somatic and psychological factors partly overlap. They include differential clinical characteristics of persons with chronic widespread pain but without sufficiently explaining somatic factors. Not all patients diagnosed with FMS meet the criteria of a persistent somatoform pain disorder. FMS is a functional disorder, in which in most patients psychosocial factors play an important role in both the etiology and course of illness. FMS can be diagnosed by looking at the history of a typical symptom cluster and excluding somatic differential diagnoses (without a tender point examination) using the modified 2010 diagnostic criteria of the American College of Rheumatology. Various levels of severity of FMS can be distinguished from a psychosomatic point of view, ranging from slight (single functional syndrome) to severe (meeting the criteria of multiple functional syndromes) forms of chronic pain disorder with somatic and psychological factors, of persistent somatoform pain disorder or of a somatization disorder. The diagnosis of FMS as a functional syndrome/stress-associated disorder should be explicitly communicated to the patient. A therapy within collaborative care adapted to the severity should be provided. For long-term management, nonpharmacological therapies such as aerobic exercise are recommended. In more severe cases, psychotherapy of comorbid mental disorders should be conducted. CONCLUSIONS: The coordinated recommendations of both guidelines can synthesize general medical, somatic, and psychosocial perspectives, and can promote graduated care of patients diagnosed with FMS.

The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial.

The objective of this study was to test the hypothesis that dry needling is more effective than sham dry needling in the treatment of myofascial pain syndrome (MPS). This was a prospective, double-blinded, randomized-controlled study conducted in an outpatient clinic. Thirty-nine subjects with established myofascial trigger points were randomized into two groups: study group (N = 22) and placebo group (N = 17). Dry needling was applied using acupuncture needles, and sham dry needling was applied in the placebo group. The treatment was composed of six sessions which were performed in 4 weeks; the first four sessions were performed twice a week (for 2 weeks) and the last two, once a week (for 2 weeks). The visual analog scale (VAS) and Short Form-36 (SF-36) were used. When compared with the initial values, VAS scores of the dry needling group following the first and sixth sessions were significantly lower (p = 0.000 and p < 0.000, respectively). When VAS scores were compared between the groups, the first assessment scores were found to be similar, but the second and third assessment scores were found to be significantly lower in the dry needling group (p = 0.034 and p < 0.001, respectively). When SF-36 scores of the groups were compared, both the physical and mental component scores were found to be significantly increased in the dry needling group, whereas only those of vitality scores were found to be increased significantly in the placebo (sham needling) group. The present study shows that the dry needling treatment is effective in relieving the pain and in improving the quality of life of patients with MPS.

Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double-blind multicenter study.

Evidence of an effect by botulinum toxins is still lacking for most pain conditions. In the present randomized, placebo-controlled, crossover multicenter study, the efficacy of botulinum toxin type A (BTX-A) was investigated in patients with persistent myofascial temporomandibular disorders (TMD). Twenty-one patients with myofascial TMD without adequate pain relief after conventional treatment participated. A total of 50 U of BTX-A or isotonic saline (control) was randomly injected into 3 standardized sites of the painful masseter muscles. Follow-up was performed after 1 and 3 months, followed by a 1-month washout period, after which crossover occurred. Pain intensity at rest was the primary outcome measure, while physical and emotional function, global improvement, side effects, and clinical measures were additional outcome measures. There was no main difference between drugs (ANOVA; P=.163), but there was a significant time effect (P<.001), so BTX-A reduced mean (SD) percent change of pain intensity by 30 (33%) after 1 month and by 23 (30%) after 3 months compared to 11 (40%) and 4 (33%) for saline. The number of patients who received a 30% pain reduction was not significantly larger for BTX-A than after saline at any follow-up visit. The number needed to treat was 11 after 1 month and 7 after 3 months. There were no significant changes after treatment in any other outcome measures, with the exception of pain on palpation, which decreased 3 months after saline injection (P<.05). These results do not indicate a clinical relevant effect of BTX-A in patients with persistent myofascial TMD pain.

A double-blind, controlled, randomized trial to evaluate the efficacy of botulinum toxin for the treatment of lumbar myofascial pain in humans.

BACKGROUND: Among all the causes of chronic low back pain, myofascial pain syndrome of the spinal stabilizer muscles is one of the most frequent, yet underconsidered sources of pain. The purpose of this prospective, randomized, double-blind, controlled trial was to evaluate the efficacy of type-A botulinum toxin (BTX-A) in relieving myofascial pain in patients experiencing mechanical low back pain due to bilateral myofascial pain syndrome involving the iliopsoas and/or the quadratus lumborum muscles. METHODS: Each of the 27 enrolled patients received a bilateral, fluoroscopically guided injection in the affected muscle(s) to randomly deliver BTX-A in one side of the low back and a control drug (randomly constituted by NaCl 0.9% or bupivacaine 0.25%) in the opposite side. To evaluate the effects of treatment on daily life activities and psychologic status, 5 different questionnaires were administered (Hospital Anxiety and Depression scale [HAD-A and HAD-D], Lattinen, Oswestry, and Spielberger State-Trait Anxiety Index). RESULTS: BTX-A injection did not significantly reduce visual analog scale scores more than treatment with NaCl or bupivacaine in the contralateral side; furthermore, the treatments administered did not result in a significant improvement of patients' daily life activities or psychologic status. Although a trend toward a decrease in postintervention visual analog scale scores could be recognized in all low back sides, this trend was significant only in the sides treated with BTX-A. CONCLUSIONS: BTX-A seems to provide significant postintervention pain relief. However, considering its high cost and the small differences compared with control treatments, its use should be reserved only for patients with pain refractory to other invasive treatments.

The therapeutic effects of acupuncture on patients with chronic neck myofascial pain syndrome: a single-blind randomized controlled trial.

Chronic neck myofascial pain syndrome (MPS) is a common disorder seen in clinics. There is no gold standard method to treat myofascial pain. We investigated the effects of acupuncture on patients with chronic neck MPS by a single-blind randomized controlled trial. A total of 35 patients were randomly allocated to an acupuncture group (AG) or a sham acupuncture group (SG). Each subject received acupuncture treatment twice per week for three consecutive weeks. The primary outcome measure was quality of life as assessed with Short Form-36, and secondary outcome measures were neck range of motion (ROM), motion-related pain, and Short-Form McGill Pain Questionnaire (SF-MPQ), as determined by a blinded investigator. The clinical assessments were made before treatment (BT) and after six acupuncture treatments (AT), as well as four weeks (F1) and 12 weeks (F2) after the end of the treatment. A total of 34 patients completed the trial. The results indicated that there is no significant difference in the ROM, motion-related pain, and SF-MPQ scores between AG and SG at AT, F1 and F2 (all p > 0.05). However, AG has greater improvement in physical functioning and role emotional of Short Form-36 quality of life at F2. The results indicate that acupuncture may be used to improve the quality of life in patients with chronic neck MPS.

Comparison of miniscalpel-needle release, acupuncture needling, and stretching exercise to trigger point in myofascial pain syndrome.

OBJECTIVE: Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. Several methods have been recommended for the inactivation of trigger points (TrPs). We carried out this study to investigate the effectiveness of miniscalpel-needle (MSN) release and acupuncture needling and self neck-stretching exercises on myofascial TrPs of the upper trapezius muscle. METHODS: Eighty-three TrPs in 43 patients with MPS were treated and randomly assigned to 3 groups: group 1 received MSN release in conjunction with self neck-stretching exercises; group 2 received acupuncture needling treatment and performed self neck-stretching exercises; and group 3, the control group, was assigned self neck-stretching exercises only. The therapeutic effectiveness was evaluated using subjective pain intensity (PI) with a visual analog scale, pressure pain threshold (PPT), and contralateral bending range of motion (ROM) of cervical spine at pretreatment, 2 weeks, and 3 months after treatment. RESULTS: The improvement of PI, PPT, and contralateral bending ROM of cervical spine was significantly greater in group 1 and 2 than that in control group at 2 weeks and 3 months follow-up. Compared with group 2, patients in group 1 had a statistically significant reduction in PI, an increase in PPT, contralateral bending ROM of cervical spine at 3 months follow-up. DISCUSSION: The effectiveness of MSN release for MPS is superior to that of acupuncture needling treatment or self neck-stretching exercises alone. The MSN release is also safe, without severe side effects in treatment of MPS.

Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial.

In this study; we aimed to compare the efficacy of local anesthetic injection and dry needling methods on pain, cervical range of motion (ROM), and depression in myofascial pain syndrome patients (MPS). This study was designed as a prospective randomized controlled study. Eighty patients (female 52/male 28) admitted to a physical medicine and rehabilitation outpatient clinic diagnosed as MPS were included in the study. Patients were randomly assigned into two groups. Group 1 (n = 40) received local anesthetic injection (2 ml lidocaine of 1%) and group 2 (n = 40) received dry injecting on trigger points. Both patient groups were given stretching exercises aimed at the trapezius muscle to be applied at home. Patients were evaluated according to pain, cervical ROM, and depression. Pain was assessed using Visual Analog Scale (VAS) and active cervical ROM was measured using goniometry. Beck Depression Inventory (BDI) was used to assess the level of depression. There were no statistically significant differences in the pre-treatment evaluation parameters of the patients. There were statistically significant improvements in VAS, cervical ROM, and BDI scores after 4 and 12 weeks in both groups compared to pre-treatment results (p < 0.05). No significant differences were observed between the groups (p > 0.05). Our study indicated that exercise associated with local anesthetic and dry needling injections were effective in decrease of pain level in MPS as well as increase of cervical ROM and decrease of depressive mood levels of individuals.

Stories about bodies: a narrative study on self-understanding and chronic pain.

OBJECTIVE: To explore experiences from a process of change for women with chronic pain. DESIGN, SETTING, AND SUBJECTS: A group-based treatment programme was intended to increase the awareness of how attitudes, habits and bodily practices are established, developed, and can be transformed, and thereby probably reduce pain. A single case story from this treatment programme is presented. A semi-structured interview was conducted with all participants about their experiences after completion of the programme. All eight women reported that they had benefited from participation. From these interviews a single case was chosen to represent the study's findings. A narrative analysis was conducted, focusing this patient's story from a phenomenological understanding of the body. RESULTS: The patient's story illuminates how events and experiences can be connected, and how she interprets her contemporary situation in the light of previous experiences. In this way, she alters her understanding and develops a new approach to her situation. Her story demonstrated how symptoms can be understood as the result of stressful habits that the body has developed as a reaction to demands from the surroundings. CONCLUSIONS: Reflection on how the body functions may lead to a new realization of how phenomena are interconnected, thus making changes possible.

The analgesic effect of botulinum-toxin A on postwhiplash neck pain.

BACKGROUND: The effectiveness of botulinum neurotoxin type A (BTXA) injections in relieving the neck pain and reduced motion that evolve after whiplash injury (WI) has been controversial. AIM OF STUDY: To test the long-term efficacy of a tender point injection of BTXA in relieving neck pain in patients with WI. METHODS: Twenty patients with cervical myofascial pain, 2 to 48 weeks after WI, were randomly assigned to receive either 200 U of BTXA or placebo at 4 tender points and were seen during the follow-ups 3, 6, 9, 12, and 24 weeks after the injections. Outcome measures included the intensity of pain as evaluated by a 10-cm Visual Analog Scale (VAS) and a 5-point Verbal Rating Scale (VRS), quality of life as evaluated by the SF-36 questionnaire, treatment efficacy as per the global assessment of the physician and patient, intensity of pain in response to mechanical pressure, range of cervical motion, and use of other therapies and their adverse effects. RESULTS: A time-dependent improvement in all the parameters was found in both groups, which was consistently larger in the BTXA-treated group, but mostly not at a significant level. Significant differences between the groups were found only in the percentages of patients who achieved 50% or more of reduction in intensity (VAS and average VRS) at 24 weeks (50% vs. 0%, P>0.05 and 70% vs. 11%, P>0.05, respectively). Systemic adverse effects tended to be more common in the BTXA-treated group (40% vs. 0%, P=0.07). CONCLUSIONS: Study results suggest that BTXA treatment has some efficacy when administered within 1 year of the WI. However, a large, well-designed clinical trial is needed to draw final conclusions.

Myofascial dysfunction associated with chronic pelvic floor pain: management strategies.

Myofascial pain as a cause of chronic pelvic pain with or without pelvic organ pathology is well-documented in the literature. Causes of this pain are multifactorial, including specific pelvic organ pathologies, neuromuscular disorders, and psychologic causes. Management of this myofascial component of chronic pelvic pain involves a multidisciplinary approach including physicians, physical therapists, neurologists, and psychiatrists. Treatment strategies, including behavioral management, medications, physical therapy, trigger point injections, neuromodulation, botulinum toxin injection, and other lesser known treatment modalities, are discussed in detail in this article.

Intramuscular and nerve root stimulation vs lidocaine injection to trigger points in myofascial pain syndrome.

OBJECTIVES: To compare the efficacies of an intramuscular stimulation technique and 0.5% lidocaine injection to trigger points in myofascial pain syndrome. PARTICIPANTS: Forty-three people with myofascial pain syndrome of the upper trapezius muscle. INTERVENTIONS: Twenty-two subjects were treated with intramuscular stimulation and another 21 with 0.5% lidocaine injection at all the trigger points on days 0, 7 and 14. RESULTS: Intramuscular stimulation resulted in a significant reduction in Wong-Baker FACES pain scale scores at all visits and was more effective than trigger point injection. Intramuscular stimulation also resulted in significant improvement on the Geriatric Depression Scale - Short Form. Local twitch responses occurred in 97.7% (42/43) of patients. All the passive cervical ranges of motion were significantly increased. Post-treatment soreness was noted in 54.6% of patients in the intramuscular stimulation group and 38.1% in the trigger point injection group, respectively, and gross subcutaneous haemorrhage (> 4 cm2) was seen in only one patient in the trigger point injection group. CONCLUSION: In managing myofascial pain syndrome, after one month intramuscular stimulation resulted in more significant improvements in pain intensity, cervical range of motion and depression scales than did 0.5% lidocaine injection of trigger points. Intramuscular stimulation is therefore recommended for myofascial pain syndrome.