Active Contraction and Passive Stretching on Myofascial Trigger Points in Shoulder

Matthew Hodgden, SPT, Rhianna Hoffman, SPT, and Kristin Arens, SPT

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40 Comments on “Active Contraction and Passive Stretching on Myofascial Trigger Points in Shoulder

  1. You stated that one of the limitations was the lack of longterm outcomes. In what kind of situation would either one of these therapies be useful?

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    • Although the patients perceived pain appeared to return to baseline at the two day follow-up, and we did not include long-term treatments in our research study, either the active contraction or passive stretching would be beneficial to decrease your patient’s pain the day of treatment. For patients in significant pain, even relief for the rest of the day is beneficial. One would want to progress the patient to interventions that would provide them with more long-term relief once their irritability decreased from use of short-term interventions. As a PT, I would use either of these interventions in conjunction with other exercises in hopes of decreasing their perceived pain the day of therapy; adding a self-stretch or isometric contraction for an home exercise program, similar to what the study interventions were, would likely further decrease the patient’s pain until the next therapy session.

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      • EDIT: Although the patient’s PPT appeared to return to baseline at the two day follow-up, and we did not include long-term treatments in our research study, either the active contraction or passive stretching would be beneficial to decrease your patient’s pain the day of treatment.

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  2. In your opinion, when looking at these two treatment types, would you use both of these techniques in a treatment session or one over the other as clinicians after doing the research? Also what other interventions would you include with these techniques for treatment of a patient?

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    • It depends on the impairments you are seeing with your patient and the goals you want to accomplish. The passive stretching intervention is more of a passive treatment by the patient as you, the therapist, are manually stretching them. This technique takes a little more time on the therapists part but may be good for patient buy-in initially and help with relaxation. You could follow this up with active stretching performed by the patient. The active contraction technique takes more effort on the patients part and may be an additional exercise you could use to follow-up with the passive stretching intervention for patient participation. Neither exercise showed significant benefits over the other so it is up to you as the clinician to decide your goal for the intervention and how you want to accomplish that goal. Other interventions you could use to treat myofascial trigger points are soft tissue mobilization, ischemic compression, myofascial release, contract relax techniques, and modalities such as e-stim and heat.

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  3. How do these methods compare to using trigger point release with a foam roll or ball?

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    • We did not look specifically at using a foam roll or ball, in either our direct methods or within our literature review. However, using a form roll or ball would be more similar to ischemic compression or transverse friction massage; rather than, active or passive elongation and shortening of the muscle. In this study we attempted to release the trigger point or at least make it less sensitive through movement of the effective muscle without direct contact of the trigger point, both the foam roll or ball are usually placed directly under the MrTPs and then rolled around similar to transverse friction massage.

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  4. In your opinion what are the pros and cons of these non-invasive treatment options compared to more invasive treatment options? Did you find anything in your research that compares outcomes between these different types of interventions, or have you seen these differences clinically?

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    • The use of these non-invasive treatment options allows us to try different interventions to see what will work best for the patient without a costly, high risk procedure. Many times, non-invasive treatments will provide the patient with relief from symptoms, and can be translated into a home program they can do themselves. The only negative aspect to these treatments is that they have the potential to not give any benefit, or the benefits are short-term. In our research, we found that the patient’s perceived level of pain decreased, regardless of treatment. I have not seen a difference between the two interventions in clinic, but tend to use both in conjunction with other exercises. I have found multiple patients with cervical pain that find relief from upper trap, levator, and other cervical muscular passive stretching; I generally teach the patient self-stretches for these if they do find relief in order to work on more stabilization exercises in clinic and decrease reliance on passive interventions.

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  5. How, if at all, do you think your results would have changed if you would have done more than one visit with manual techniques? Would you expect more long-term results or improvements?

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    • Based on the literature the results would still likely still be mixed, meaning additional therapy would reduce some symptoms in some patients but would not be beneficial for all patients. However, one visit is a huge limitation in our study because any technique that we complete in physical therapy should be performed more than one time to show long term benefits. The technique can be accurate for very short term management; however, we can not generalize anything from our study for the long term outcomes because it is not feasible to assume one treatment was able to “cure” these patients from their MrTP.

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  6. The follow-up period was 2 days for this study. Do you think the results would be different if the follow-up was shorter or longer in duration?

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    • With a longer follow-up we would hypothesize that they would return back to their baseline, simply because one treatment is not going to be able to show long term benefits as shown in other research involving both manual therapy, therapeutic exercises or modality interventions. If the follow-up was shorter than 2 days we may have similar results to our short term immediate relief interventions, or we may have an increased sensitivity seen just due to the direct effects that were caused within the muscle causing mild soreness.

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  7. With the current trend that we saw in our research we could hypothesize that a longer duration would likely have similar results to what we found given that PPT values basically returned to what they were at pre-intervention. However, it would be interesting to see if the NRS values changed with a longer follow-up period, i.e. whether the patients felt like their improvements in pain were sustained for more than 2 days or whether they felt like the short intervention “wore off”. Doing a One day follow-up would be interesting to look into for further research but one should consider the clinical usefulness of an intervention that gives relief for one day. Best case scenario, we would want to provide an intervention or combination of interventions, as my peers have stated in the comments above, to provide the best relief for the longest amount of time.

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  8. Do you feel that your results would have changed with even more detailed inclusion criteria? For example what do you think the results would be more conclusive if you only did students and not faculty or vice versa? I noticed there was as STD of 13 years. Or what if you just did pts with shoulder girdle pain? I would be curious to see if PPT would change still.

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    • Overall the results could have been varied vastly with our inclusion criteria; however, I think the more interesting and relevant inclusion criteria would be to only include patients that are suffer and wanting to receive treatment for the symptoms that are expressed through the trigger point. That way we can conclude active trigger points are being included and not assuming that a latent trigger point was found under all four criteria. It would be interesting to see if are able to change both PPT and NRS if only active trigger points were included.

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  9. For the active contraction group, was the resistance standard across all subjects? I am thinking if you have a researcher giving the same resistance to a stronger, bigger subject and another subject of smaller stature and maybe not as strong. Maybe some subjects were worked to muscular fatigue or repetition maximum and others were not? Did you see any differences within the active contraction intervention group?

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    • Great question, Mark! We attempted to control for this variable by having one researcher complete all interventions, both passive and active. Although the researcher did attempt to give the same resistance on her part between patients, you are likely correct that some patients gave the researcher more resistance than others, as we had a wide range of body types/male vs. female/normal activity level, etc…. Kristin can better answer if she noted a significant difference between participants with varying stature and the resistance they provided during the active contraction intervention.

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  10. How will this research impact the way you practice? What will you take to the clinic with you concerning what you have learned throughout the research project? (Not necessarily only related to the objective results)

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    • One of the biggest things I learned is the impact that patient’s everyday activities can have a fairly apparent impact on your results. We had a few comment about activities that were outside of their normal routine, which would likely impact the treatment you did that day (positively or negatively). As a therapist, we can recommend doing or not doing certain activities based upon their symptoms and progress, but everyone has commitments they need to participate in. Second, I learned that therapy will likely be trial-and-error for what works best for certain patients, as seen with our study and the other literature we found regarding active contraction vs. passive stretching results. Neither intervention showed a significant difference over the other; I will likely use both techniques to treat patients, focusing on what they feel the most relief from.

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  11. Just curious to know if those more invasive interventions you mentioned such as acupuncture, dry needling, and injections provide short-term relief similar to what you were seeing in your two non-invasive interventions, or do they seem to have any more long-term effects?

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  12. During my time in the clinic, I’ve seen or spoken with patients who have experienced many of these more invasive interventions. Dry needling and acupuncture appear to have more short-term effects, similar to those of our study. They are repeated, ideally, 2-3 times per week for best results. Injections are more long-term, if effects are noticed by the patient, due to the stimulus actually being present for longer, as opposed to dry needling/acupuncture/our study interventions that are provided and stimulus taken away in that same treatment. That being said, research is mixed and patients react to the above mentioned interventions differently, with some patients feeling relief from certain interventions, while other patients react better to a different intervention.

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  13. Now that your study is completed, is there anything that you would have done differently? Also, how did the other non-invasive treatments that you stated compare to your interventions?

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    • I think the biggest things we would have done differently were a longer intervention time, for example a 10-15 minute intervention vs. 3-5 min intervention, and a longer follow up period (4-5 days post intervention). One thing we also talked about was doing a longer intervention and doing it over multiple sessions (for example 1 to 3 week long intervention period with 3-4 sessions a week). We would hypothesize a difference in outcomes with this approach. In our literature review, we found a lot of different non-invasive treatments that have been studied such as soft tissue mobilization techniques such as ischemic compression, biophysical agents and modalities such as ultrasound, e-stim, laser, transverse friction massage, and muscle energy techniques. Currently, there is no over arching evidence to suggest one non-invasive intervention over the other.

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  14. Why did you choose to perform stretching for the passive technique rather than sustained compression and/or pin-and-stretch? Do you think either of these other two would have produced different results?

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    • There is a lot of research involving sustained compression and pin-and-stretch most of which show mixed results. There is very little research involved just passive stretching, and it is generally is a big part of a physical therapy session involving manual therapy. So we wanted to attempt to show if passive stretching alone could be a good component in the treatment of trigger points.

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  15. If you were to go back and do this study again, what aspects would you want to keep and what would you modify? Were there other outcome measures that you thought about including but decided not to? If so, what were they and why did you go in that direction?

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    • Overall the methods that we choose was very beneficial. If possible it would be beneficial to include multiple treatments and actual patients seeking treatment from the trigger points. We thought about adding functional limitations as an outcome measure but because we included patients that may have been experience latent trigger points the majority of our patients would not have any functional limitations and that is why we decided to not include this outcome measure.

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  16. Mark, being the person who performed the intervention, I did notice some variability with the resistance I applied. However, when you look at the middle trap, for instance, these are relatively small muscles that when isolated are weak in most subjects, so it did not take much pressure to provide resistance through the ROM. However, for the patients, I tried to offer enough resistance that they could perform the exercise but also had the contraction be challenging. While there was some variability, I would not call it significantly different from patient to patient.

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  17. The 2016 class had a group that did a similar study that compared soft tissue mobilization techniques for treatment of trigger points including ischemic compression (sustained compression). So we did not look at this aspect in our study as the previous class studied it. We wanted to compare an active treatment vs a passive treatment so passive stretching was one we picked since it is performed a lot in clinic with this patient population. Future research could look at a pin-and-stretch technique. Both of these techniques could produce different results from what we found as these may be classified as a more “intense” intervention. Future research could look at these two techniques and compare their results to see if one is more effective than another.

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  18. Your conclusions found that no treatment/intervention had better outcomes than another. Within the clinical setting, what do you believe would be your go to method or your first intervention that you would utilize? Obviously, much of this will be dependent on the patient; however, have you been able to incorporate any of your findings into clinical practice?
    Also, if you were to do this study again, would you implement any sort of self-stretching or trigger point interventions that allowed the patient to be more self-efficacious?

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    • Due to most, if not all, the research on the treatment of myofascial trigger points having mixed results in their effectiveness; it is important to incorporate a little bit of everything and become adaptable to changing the initial plan if it is not showing any benefit to that particular patient. This particular study wanted to look at the effectiveness of a single treatment so implementing a self-stretching or other self intervention would allow the possibility that long term effects may be changed and affected, but would change the overall purpose of the study. If we were to do this study again, it would be beneficial to extend the number of treatment as well as incorporate a home program that could potentially show some long term effects of these interventions.

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  19. Did you find one of the interventions easier and less time consuming to perform than the other? Just curious if that would help you determine which one to start with since the results were inconclusive.

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    • Both interventions were fairly easy to perform and should be able to be completed by any entry level PT or PTA. Passive stretching allowed the patient to just relax where active contraction did involved the patient to participate in the intervention, so from a patient stand point it would be easier to complete the passive stretching intervention. As far as which intervention to start with in therapy would be patient dependent and dependent on if active movement is painful or even possible.

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  20. What lead you to decide on 20 second holds for the passive stretching? Also, if a participant had multiple trigger points in the shoulder did you treat only one of them?

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    • The 20 second holds for the passive stretching group was an arbitrary number decided upon between all the researchers. We did try to keep both the active and passive groups relatively consistent for total treatment time. If a participant had multiple trigger points, a subjective indication of “which is the worst?” was the deciding factor for the trigger point of treatment.

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  21. What was your original hypothesis of this study? Did you expect one of the treatments to work better than the other? Or were the results consistent with your original hypothesis?

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  22. We hypothesized that there would be a difference between the treatments, but did not hypothesize which would have a greater improvement in the patient’s symptoms. Therefore, the results were not consistent with our hypothesis due to both interventions providing short term symptom improvement, with neither intervention showing significantly better results than the other.

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  23. Did you guys control for consistent resistance between patients during the active contraction interventions? Did the same researcher apply all resistance, and was more force applied to bigger patients to account for their possible increased strength?

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    • Chelsie, I applied the intervention to all patients so I could control for the amount of resistance applied and make it as consistent as I could with all patients. Yes, some patients required more resistance than others due to strength differences but my and my researchers goals were to make the contraction possible but challenging at the same time. Keep in mind, the muscles we provided resistance against (middle trap for example) are small and when isolated are often untrained in the general population so not much resistance was required to make the contraction challenging for all patients.

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