Denneny D, Frawley HC, Petersen K, et al. Trigger Point Manual Therapy for the Treatment of Chronic Noncancer Pain in Adults: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2019 Mar;100(3):562-577. doi: 10.1016/j.apmr.2018.06.019. Epub 2018 Jul 17. (Systematic review)

OBJECTIVE: To determine the effectiveness of trigger point manual therapy (TPMT) for reducing chronic noncancer pain and associated problems in adults, by analyzing all relevant randomized controlled trials (RCTs).

DATA SOURCES: We searched databases and clinical trials registers from their inception to May 2017.

STUDY SELECTION: We included RCTs in any language that recruited patients older than 18, with pain of 3 months' duration or more. We assessed pain, function, and patient-reported improvement as outcomes.

DATA EXTRACTION: Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesized narratively.

DATA SYNTHESIS: We combined all data using a random-effects model and assessed the quality of evidence using GRADE. A total of 19 trials (involving 1047 participants) met inclusion criteria, representing TPMT treatment of musculoskeletal, pelvic, and facial pain. No effect was found for short-term pain relief (mean standardized difference -0.53; 95% confidence interval [CI], -1.08 to 0.02). One small study showed a longer-term benefit for pain (mean standardized difference -2.00; 95% CI, -3.40 to -0.60) but with low confidence in the effect. Significant gains emerged for function (mean standardized difference -0.77; 95% CI, -1.27 to -0.26) and in patient global response (odds ratio 3.79; 95% CI, 1.86-7.71) from 4 studies, but not for health-related quality of life.

CONCLUSIONS: Evidence for TPMT for chronic noncancer pain is weak and it cannot currently be recommended.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Nurse 5 / 7
Physician 4 / 7
Comments from MORE raters

Nurse rater

The methods were very detailed and it is a meta-analysis of randomized control trials. It is interesting in light of the dilemma we face when successfully treating chronic pain. Unfortunately trigger point manual therapy does not seem to be effective.

Nurse rater

Negative findings can be useful. It appears from this study that TPMT is not a useful tool to combat chronic pain.

Nurse rater

Denneny et al. (2018) determined the effectiveness of TPMT for reducing chronic non-cancer pain and associated problems in adults. The researchers defined chronic pain as pain that lasts more than 3 months and referenced Aquiler et al. (2009). This literature does not support the definition of chronic pain as presented by Denneny et al. (2018) and is 9 years old. Cochrane could support (2017) it. Further Denneny et al. (2018) described the aim of the review – to determine the effectiveness of TPMT for treating chronic non-cancer pain in adults and added myofascial pain (muscle injury, repetitive strain) yet the reviewed literature included 2 studies examining intravaginal tissues. This is confusing as chronic non-cancer pain and myofascial pain in particular has been associated with MSK pain, OA, RA and fibromyalgia. The authors comment a lack of follow up noted within the literature; however, they also identify that they did not anticipate any changes in pain at follow up.

Physician rater

This is a useful, objective study. The lack of evidence for manual trigger point therapy is helpful in counselling patients to avoid spending their money on this treatment, that is not covered by provincial health care plans.

Rehab Clinician (OT/PT) rater

MF TrP's have been identified as muscular dysfunctions that need to be addressed. We have various ways of doing this. This article is a great one that questions the true value of the TrP's in the bigger picture and there is not a lot of evidence that we should focus on this clinically. Good read.

Rehab Clinician (OT/PT) rater

The information was well presented and had logical explanations for the conclusions of the study. They wisely pointed out that they could not recommend a treatment with a primary goal of pain relief that was not supported by evidence. At least, we know what short comings there may be to some of our treatment choices.
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