Trigger points and sensitized acupoints:same book,different covers?

Acupoints and trigger points in traditional Chinese medicine represent two different minimally invasive therapy systems-based,respectively,on traditional acupuncture and dry needles.Many studies argue that trigger points and traditional acupoints are conceptually similar because they generally have identical locations on the human body.However,whether trigger points contribute to the formation of the traditional acupuncture technique is controversial.Although many relevant studies have been conducted,this controversy continues to hinder the development of both disciplines.Recently,researchers of Chinese acupuncture have proposed the“acupoint sensitization”theory,which postulates that traditional acupoints may be sensitized by diseases,environments,and therapies.This turns them into a“sensitized state.”Recent studies suggest that trigger points and sensitized acupoints share similar biological properties.To clarify the above-mentioned confusion,we reviewed relevant studies on these two concepts and attempted to analyze their relationship.In this paper,we provide a general summary of acupoint sensitization theory and sensitized acupoints.We then compare trigger points with sensitized acupoints by categorizing their similarities and differences,including location and range,pathological morphology,pain perception,surface temperature effects,and bioelectrical properties.We believe that,because trigger points and sensitized acupoints have many shared properties,they might constitute“the same book with different covers.”

Understanding of myofascial trigger points

Objective To investigate the current practice of myofascial pain syndrome （MPS） including current epidemiology, pathology, diagnosis and treatment. Data sources The data analyzed in this review were mainly from relevant articles without restriction on the publication date reported in PubMed, MedSci, Google scholar. The terms ＂myofasial trigger points＂ and ＂myofacial pain syndrome＂ were used for the literature search. Study selection Original articles with no limitation of research design and critical reviews containing data relevant to myofascial trigger points （MTrPs） and MPS were retrieved, reviewed, analyzed and summarized. Results Myofascial pain syndrome （MPS） is characterized by painful taut band, referred pain, and local response twitch with a prevalence of 85% to 95% of incidence. Several factors link to the etiology of MTrPs, such as the chronic injury and overload of muscles. Other factors, such as certain nutrient and hormone insufficiency, comorbidities, and muscle imbalance may also maintain the MTrP in an active status and induce recurrent pain. The current pathology is that an extra leakage acetylcholine at the neuromuscular junction induces persistent contracture knots, relative to some hypotheses of integration, muscle spindle discharges, spinal segment sensitization, ect. MTrPs can be diagnosed and localized based on a few subjective criteria. Several approaches, including both direct and supplementary treatments, can inactivate MTrPs. Direct treatments are categorized into invasive and conservative. Conclusion This review provides a clear understanding of MTrP pain and introduces the most useful treatment approaches in China.

Observation on therapeutic effect of electroacupuncture plus Tanbo-plucking the trigger points for scapulohumeral periarthritis

Objective: To observe the clinical efficacy of electroacupuncture (EA) plus Tanbo-plucking the trigger points for scapulohumeral periarthritis (SP). Methods:A total of 80 patients with SP were randomized into an observation group and an EA group by the random number table, with 40 cases in each group. The EA group was treated with EA therapy, and the observation group was treated with EA therapy plus Tanbo-plucking the trigger points. After treatment, the visual analog scale (VAS) and Melle scores of the two groups were compared to evaluate the improvement of shoulder pain and functional activity, and meanwhile the clinical efficacy was observed. Results: After treatment, the total effective rate of the observation group was 95.0% and the cure and markedly effective rate was 72.5%. The total effective rate of the EA group was 87.5% and the cure and markedly effective rate was 42.5%. There was no significant difference in the total effective rate between the two groups (P>0.05). The cure and markedly effective rate of the observation group was higher than that of the EA group, and the difference between the two groups was statistically significant (P<0.05). After treatment, the intra-group differences in VAS and Melle scores of both groups were statistically significant (bothP<0.001). The inter-group differences in the changes of the VAS and Melle scores after treatment were statistically significant (bothP<0.001). Conclusion: EA plus Tanbo-plucking the trigger points has a better curative effect than EA therapy alone in the treatment of SP.

Study on the relationship between relieving energy crisis in myofascial trigger points with An-Pressing manipulation and AMPK/PGC-1α pathway activation

Objective To explore the mechanism of An-Pressing manipulation in relieving energy crisis in chronic myofascial trigger points(MTrPs)by observing the effects of An-Pressing manipulation on adenosine triphosphate(ATP),adenosine 5′-monophosphate(AMP)-activated protein kinase(AMPK)/peroxisome proliferator-activated receptorγcoactivator 1α(PGC-1α)pathway and mitochondrial ultrastructure of skeletal muscle cells in MTrPs rats.Methods Forty-eight male Sprague-Dawley rats were randomly divided into a blank group,a model group,a lidocaine group,and an An-Pressing manipulation group,with 12 rats in each group.The model group,lidocaine group and An-Pressing manipulation group were used to replicate the MTrPs rat model by blunt shock and centrifugal motion method.After modeling,the An-Pressing manipulation group was subjected to 7 times An-Pressing manipulation,once every other day;the lidocaine group was treated with 3 times of injection of lidocaine at the MTrPs,once every 6 d.The blank group and the model group were fed normally without intervention.After the intervention,local muscle tissue was taken to detect the content of ATP and the expression of AMPK,phosphorylated AMPK(phospho-AMPK),PGC-1α,and glucose transporter 4(GluT4),and the ultrastructure of mitochondria was observed under an electron microscope.Results Compared with the blank group,the ATP content in the model group was decreased(P<0.05),the protein expression levels of phospho-AMPK,PGC-1α,and GluT4 and the ratio of phospho-AMPK to AMPK were decreased(P<0.05);under the electron microscope,the number of mitochondria decreased,and they were deformed,small in volume,and had deformed cristae.Compared with the model group,the ATP contents in the An-Pressing manipulation group and the lidocaine group were increased(P<0.05),and the protein expression levels of phospho-AMPK,PGC-1α,and GluT4 and the ratio of phospho-AMPK to AMPK were increased(P<0.05);under the electron microscope,the number of mitochondria increased,the shape and size of the mitochondria were basically normal,and the cristae could be seen.Compared with the lidocaine group,phospho-AMPK and the ratio of phospho-AMPK to AMPK in the An-Pressing manipulation group were increased(P<0.05);under the electron microscope,the numbers of mitochondria were similar,and the shape and size of the mitochondria were basically normal without swelling,and the cristae could be observed.Conclusion An-Pressing manipulation can increase the ATP content in MTrPs tissue,improve the expression levels of PGC-1α and GluT4 proteins and the ratio of phospho-AMPK to AMPK;its mechanism may relate to the activation of AMPK/PGC-1α signaling pathway to promote the repair of mitochondrial damages.

Similarities and differences between the trigger point of myofascial pain and the traditional meridian points

In recent years,the treatment of myofascial pain trigger point is a relatively popular technology,many people regard it as"Ashi point"in meridian theory,but compared with the traditional meridian theory,the description of myofascial pain trigger point is more intuitive and easier to master.This paper expounds the similarities and differences between myofascial pain trigger point and traditional meridian theory from the aspects of theory,basic research and clinical application,in order to provide a specific idea for the scientific interpretation of meridian phenomenon in traditional Chinese medicine.

Instrumented assisted soft tissue mobilization vs extracorporeal shock wave therapy in treatment of myofascial pain syndrome

BACKGROUND Active myofascial trigger points(TrPs)often occur in the upper region of the upper trapezius(UT)muscle.These TrPs can be a significant source of neck,shoulder,and upper back pain and headaches.These TrPs and their related pain and disability can adversely affect an individual’s everyday routine functioning,work-related productivity,and general quality of life.AIM To investigate the effects of instrument assisted soft tissue mobilization(IASTM)vs extracorporeal shock wave therapy(ESWT)on the TrPs of the UT muscle.METHODS A randomized,single-blind,comparative clinical study was conducted at the Medical Center of the Egyptian Railway Station in Cairo.Forty patients(28 females and 12 males),aged between 20-years-old and 40-years-old,with active myofascial TrPs in the UT muscle were randomly assigned to two equal groups(A and B).Group A received IASTM,while group B received ESWT.Each group was treated twice weekly for 2 weeks.Both groups received muscle energy technique for the UT muscle.Patients were evaluated twice(pre-and posttreatment)for pain intensity using the visual analogue scale and for pain pressure threshold(PPT)using a pressure algometer.RESULTS Comparing the pre-and post-treatment mean values for all variables for group A,there were significant differences in pain intensity for TrP1 and TrP2(P=0.0001)and PPT for TrP1(P=0.0002)and TrP2(P=0.0001).Also,for group B,there were significant differences between the pre-and post-treatment pain intensity for TrP1 and TrP2 and PPT for TrP1 and TrP2(P=0.0001).There were no significant differences between the two groups in the post-treatment mean values of pain intensity for TrP1(P=0.9)and TrP2(P=0.76)and PPT for TrP1(P=0.09)and for TrP2(P=0.91).CONCLUSION IASTM and ESWT are effective methods for improving pain and PPT in patients with UT muscle TrPs.There is no significant difference between either treatment method.

Modulation effects of pressing manipulation on local inflammatory responses and ERK/NF-κB pathway in trigger point model rats

Objective:To investigate the mechanism of trigger point deactivation induced by pressing manipulation in a rat model and to explore its potential regulation of the inflammatory response through the extracellular signal-regulated kinase(ERK)/nuclear factor-κB(NF-κB)pathway.Methods:Fifty male Sprague-Dawley rats were randomly divided into a blank group,a model group,a pressing manipulation group,an ERK agonist group,and a pressing manipulation+ERK agonist group,with 10 rats in each group.Except for the blank group,rats in other groups were used to establish the trigger point rat model using the blunt blow combined with the eccentric exercise method.The pressing manipulation group underwent pressing manipulation intervention at the trigger points.The ERK agonist group received an injection of recombinant human epidermal growth factor via the tail vein.The pressing manipulation+ERK agonist group received interventions from both the pressing manipulation and ERK agonist groups.The pressure pain threshold(PPT)was measured by a mechanical pain threshold detector before and after the intervention.The histological changes were evaluated by hematoxylin-eosin staining after the intervention;the expression levels of ERK,phosphorylated ERK(p-ERK),NF-κB p65(p65),phosphorylated NF-κB p65(p-p65),and phosphorylated NF-κB inhibitor(p-IκB)were detected by Western blotting;the levels of interleukin(IL)-1β,IL-6,and tumor necrosis factor(TNF)-αwere detected by enzyme-linked immunosorbent assay.Results:The PPT increased(P<0.05);the inflammatory cells disappeared;the ratios of p-ERK/ERK,p-p65/p65,and p-IκB/β-actin,also the levels of IL-1β,IL-6,and TNF-αall decreased in the pressing manipulation group after the intervention compared with the model group(P<0.05).The PPT decreased significantly(P<0.05),the inflammatory cell presence increased,and the ratios of p-ERK/ERK and p-p65/p65 were elevated(P<0.05);additionally,the levels of IL-6 and TNF-αwere significantly higher in the pressing manipulation+ERK agonist group compared with the pressing manipulation group(P<0.05).The PPT was significantly lower(P<0.05),the inflammatory cell count was higher,the ratios of p-ERK/ERK and p-IκB/β-actin and the levels of IL-1βand TNF-αwere significantly higher in the ERK agonist group compared with the pressing manipulation+ERK agonist group(P<0.05).Conclusion:Pressing manipulation can effectively alleviate inflammation and pain in trigger point model rats,potentially by inhibiting the ERK/NF-κB signaling pathway.

Expert consensus on the diagnosis and treatment of myofascial pain syndrome

Myofascial pain syndrome(MPS)is characterized by myofascial trigger points and fascial constrictions.At present,domestic and foreign scholars have not reached a consensus on the etiology and pathogenesis of MPS.Due to the lack of specific laboratory indicators and imaging evidence,there is no unified diagnostic criteria for MPS,making it easy to confuse with other diseases.The Chinese Association for the Study of Pain organized domestic experts to formulate this Chinese Pain Specialist Consensus on the diagnosis and treatment of MPS.This article reviews relevant domestic and foreign literature on the definition,epidemiology,pathogenesis,clinical manifestation,diagnostic criteria and treatments of MPS.The consensus is intended to normalize the diagnosis and treatment of MPS and be used by first-line doctors,including pain physicians to manage patients with MPS.

Comparison between four treatment modalities for active myofascial triggers points

Aim:The study aimed at the painful trigger points(TrPs)for the purpose of ablating muscle spasms and restoring normal muscle length to find the most effective treatment for alleviating pain and improving mouth range of motion in patients with myofascial pain dysfunction.Methods:We enrolled 72 patients with pain and reduced mouth opening due to temporomandibular joint dysfunction.Patients assigned to four groups and four treatment modalities used to treat myofascial TrPs pain.We used mean and standard deviation values.The Mann–Whitney U-test was used to compare the two groups.The Wilcoxon signed-rank test was used to study the changes by the time in mean pain scores.The Student’s t-test was used to compare maximum mouth opening(MMO)groups.Then paired t-test was also used to study the changes of time in an MMO.Results:The results showed that pulsed electromagnetic field(PEMF)therapy is the most effective treatment modality regarding for pain relief.Both the anesthesia and PEMF groups showed a reduction in mean pain scores throughout all follow-up periods,and a statistically significant increase in mean MMO.Conclusion:The findings suggest that PEMF is the most effective treatment for alleviating pain and improving mouth range of motion in patients with myofascial pain.

Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome

Prostatitis comprises of a group of syndromes that affect almost 50% of men at least once in their lifetime and makeup the majority of visits to the Urology Clinics.After much debate, it has been divided into four distinct categories by National Institutes of Health namely(1) acute bacterial prostatitis;(2) chronic bacterial prostatitis;(3) chronic prostatitis/chronic pelvic pain syndrome(CP/CPPS) which is further divided into inflammatory and non-inflammatory CP/CPPS; and(4)asymptomatic inflammatory prostatitis. CP/CPPS has been a cause of great concern for both patients and physicians because of the lack of presence of thoroughinformation about the etiological factors along with the difficult-to-treat nature of the syndrome. For the presented manuscript an extensive search on PubM ed was conducted for CP/CPPS aimed to present an updated review on the evaluation and treatment options available for patients with CP/CPPS. Several diagnostic criteria's have been established to diagnose CP/CPPS, with prostatic/pelvic pain for at least 3 mo being the major classifying symptom along with the presence of lower urinary tract symptoms and/or ejaculatory pain. Diagnostic tests can help differentiate CP/CPPS from other syndromes that come under the heading of prostatitis by ruling out active urinary tract infection and/or prostatic infection with uropathogen by performing urine cultures, Meares-Stamey Four Glass Test, Preand Post-Massage Two Glass Test. Asymptomatic inflammatory prostatitis is confirmed through prostate biopsy done for elevated serum prostate-specific antigen levels or abnormal digital rectal examination. Researchers have been unable to link a single etiological factor to the pathogenesis of CP/CPPS, instead a cluster of potential etiologies including atypical bacterial or nanobacterial infection, autoimmunity, neurological dysfunction and pelvic floor muscle dysfunction are most commonly implicated. Initially monotherapy with anti-biotics and alpha adrenergic-blockers can be tried, but its success has only been observed in treatment nave population. Other pharmacotherapies including phytotherapy, neuromodulatory drugs and anti-inflammatories achieved limited success in trials. Complementary and interventional therapies including acupuncture, myofascial trigger point release and pelvic floor biofeedback have been employed. This review points towards the fact that treatment should be tailored individually for patients based on their symptoms. Patients can be stratified phenotypically based on the UPOINT system constituting of Urinary, Psychosocial, Organ-specific, Infectious, Neurologic/Systemic and symptoms of muscular Tenderness and the treatment algorithm should be proposed accordingly. Treatment of CP/CPPS should be aimed towards treating local aswell as central factors causing the symptoms. Surgical intervention can cause significant morbidity and should only be reserved for treatment-refractory patients that have previously failed to respond to multiple drug therapies.

Clinical symptoms of cervical and shoulder MTrPs combined with the "third stage" dialectical traction in the treatment of cervical radiculopathy and its effect on the serum inflammatory factors of patients

Objective:To observe the clinical efficacy of acupotomology in the treatment of cervical and shoulder myofascial pain trigger point for cervical radiculopathy,and to detect its effect on COX-2,PGE2,5-HT,TNF-α and other inflammatory factors.Methods:A total of 110 CSR patients were selected as the research objects and divided into observation group(Acupotomology to release the trigger points of myofascial pain in neck and shoulder combined with"three-stage"dialectical traction method)and control group(conventional acupuncture combined with"Stage 3"dialectical traction)with 55 cases.Before and after treatment,the two groups were compared by improving the efficacy of MacNab,simplifying the SCORE of Mc Gill Pain Scale,measuring cervical curvature and serum levels of inflammatory factors such as COX-2,PGE2,5-HT and TNF-α.Results:After two weeks of treatment,the total effective rate of the observation group was 96.36%,higher than that of the control group(83.63%),and the difference was statistically significant(P<0.05).After the treatment,PRI,VAS,PPI and other scores of the two groups were all lower than those before the treatment,with statistical significance(P<0.05).However,there was no statistically significant difference in PRI,VAS and PPI scores between the two groups after treatment(P>0.05).The serum inflammatory factors of coX-2,PGE2,5-HT and TNF-αin the two groups were significantly lower after treatment than before treatment(P<0.05).However,the comparison of cox-2,PGE2,5-ht and TNF-αbetween the two groups showed no statistical significance(P>0.05).The cervical curvature values measured after treatment were significantly increased compared with those before treatment,and the difference was statistically significant(P<0.05).There was no statistically significant difference between the two groups(P>0.05).Conclusion:The combination of acumotomology and"three-stage"dialectical traction method can significantly improve the pain and discomfort of patients with cervical radiculopathy,significantly reduce the symptoms,restore the physiological curvature of cervical vertebra,and reduce the inflammatory factors in serum.

The Comparison of trigger point acupuncture and traditional acupuncture

Trigger point（TrP） acupuncture（dry needling）,the use of solid filiform needles at TrPs,has been developed from a comprehensive integration and adaptation of traditional acupuncture using current understandings of TrPs.During the past twenty years,the concept and technique continues to evolve,with a potential to expand to other conditions beyond myofascial pain syndromes that can be managed via stimulating TrPs.In this article,we compared TrP acupuncture and traditional acupuncture from the following aspects：points of needle insertion,needles and needling techniques,and therapeutic indications.Traditional acupuncture encompasses an abundance of methods and techniques in acupuncture practices and has been widely used and studied for a variety of disorders.With unique specific characteristics,TrP acupuncture further develops traditional acupuncture theories,especially the concepts of Ashi point.The location of TrPs,their distribution pattern and pain indication are similar to those of traditional acupoints;the selection of needles,depth of needle insertion,and manipulation techniques are part of traditional acupuncture.TrP acupuncture is thus an integral part of traditional acupuncture.

Clinical observation of needling gluteus medius muscle trigger point plus chiropractic for sacroiliac joint subluxation

Objective:To observe the clinical effect of needling gluteus medius muscle trigger point (TrP) plus chiropractic for sacroiliac joint subluxation.Methods:A total of 124 cases conforming to the inclusion criteria of sacroiliac joint subluxation were classified by anterior subluxation and posterior subluxation,and randomized into a TrP group and a conventional group respectively.There were 63 patients with anterior subluxation who were randomized into a TrP group of 32 cases (including 4 dropped out cases) and a conventional group of 31 cases (including 3 dropped out cases);and 61 patients with posterior subluxation who were randomized into a TrP group of 31 cases (including 3 dropped out cases) and a conventional group of 30 cases (including 3 dropped out cases).Patients in the TrP group received the treatment of needling gluteus medius muscle TrP plus chiropractic,while patients in the conventional group received conventional acupuncture treatment plus chiropractic.The treatment was done twice a week for a succession of 8 weeks.Then,the pain visual analog scale (VAS),Oswestry disability index (ODI) and therapeutic efficacy were evaluated.Results:After treatment,the total effective rate of TrP group with anterior subluxation was 96.9%,higher than 77.4% in the conventional group,the difference showed a statistical significance (P<0.05);the total effective rate was 93.5% in the TrP group with posterior subluxation,higher than 73.3% in the conventional group.After treatment,the VAS and ODI scores in both groups dropped obviously,the differences showed statistical significance (all P<0.05);the scores of VAS and ODI in the TrP group were obviously lower than those in the conventional group (all P<0.05).Conclusion:Needling gluteus medius muscle TrP plus chiropractic had a better therapeutic effect than conventional acupuncture plus chiropractic for sacroiliac joint subluxation.

Evidence and Expert Opinions:Drying Needling versus Acupuncture(Ⅱ)--The American Alliance for Professional Acupuncture Safety(AAPAS)White Paper 2016

In the United States and other Western countries, dry needling has been a topic in academic and legal fields. This White Paper is to provide the authoritative information of dry needling versus acupuncture to academic scholars, healthcare professionals, administrators, policymakers, and the general public by providing the authoritative evidence and expertise regarding critical issues of dry needling and reaching a consensus. We conclude that Dr. Travell, Dr. Gunn, Dr. Baldry and others who have promoted dry needling by simply rebranding（1） acupuncture as dry needling and（2） acupuncture points as trigger points（dry needling points）. Dry needling simply using English biomedical terms（especially using ＂fascia＂ hypothesis） in replace of their equivalent Chinese medical terms. Dry needling is an over-simplified version of acupuncture derived from traditional Chinese acupuncture except for emphasis on biomedical language when treating neuromuscularskeletal pain（dry needling promoters redefined it as ＂myofascial pain＂）. Trigger points belong to the category of Ashi acupuncture points in traditional Chinese acupuncture, and they are not a new discovery. By applying acupuncture points, dry needling is actually trigger point acupuncture, an invasive therapy（a surgical procedure） instead of manual therapy. Dr. Travell admitted to the general public that dry needling is acupuncture, and acupuncture professionals practice dry needling as acupuncture therapy and there are several criteria in acupuncture profession to locate trigger points as acupuncture points. Among acupuncture schools, dry needling practitioners emphasize acupuncture＇s local responses while other acupuncturists pay attention to the responses of both local, distal, and whole body responses. For patients＇ safety, dry needling practitioners should meet standards required for licensed acupuncturists and physicians.

Dry needling:a de-meridian style of acupuncture

Recently, the educators OT ury Neeclllng （DN） in tne West ofterl proctaime that DN is not acupuncture, and thus DN practitioners do not need to have the same training as acupuncturists. Their primary reason is that DN does not use the meridian theory of traditional Chinese medicine （TCM）. in this paper, the authors refuted this claim. Through a systemic review on the global ＂Acupuncture Fever＂, there are several different manifestations of ＂De- Meridian＂ phenomena （meridian theory is not required for acupuncture and other related modalities）. Although De-Meridian has played a positive role in the development of acupuncture, it does not mean ＂De-Acupuncture＂ （modaiities derived from but different from acupuncture）. Given the clear definition of acupuncture by WHO, even though DN has certain attributes of De-Meridian that is similar to other forms of novel needling therapies, all of them belong to acupuncture. DN is a style of contemporary acupuncture, also called Trigger points （TrPs） acupuncture. This is because not only these myofascial TrPs stimulated by DN have always been acupoints, the needles and techniques used in DN are no different than acupuncture. Moreover, the mechanisms of DN and acupuncture are one in the same. The development of modern DN theory and its application are closely associated with the clinical trials and research of acupuncture. On the other hand, researches and clinical applications on myofascial TrP have highlighted the importance of stimulating reflex points in the clinic. However, as it refuses to inherit the theory and experience from thousands of years of acupuncture practice, it has shown obvious shortcomings in clinical applications.