Treatment Rationale
Problem: Patient is a 48 yo female s/p MVA, 8 weeks with complaints of headaches and neck pain. She notes increased frequency and intensity of her headaches with deep palpation of her right trapezius.
Justification: Hsueh et al.(2) performed a study that compared electrical nerve stimulation (ENS), electrical muscle stimulation (EMS) and a placebo treatment for patients who had myofascial trigger points in one side of their upper trapezius. It was reported that the ENS treatment was more effective at providing immediate pain relief than the EMS group and the placebo group. The ENS group had a lower pain intensity as measured by the VAS and an increased pain pressure threshold as measured with an algometer. The EMS treatment was better than the ENS and the placebo group at improving range of motion as measured with goniometry. Rodríguez-Fernández et al.(3) performed a study that compared a burst-type TENS treatment with a placebo group when treating patients with latent myofascial trigger points in their upper trapezius muscle. They discovered that the TENS group had a significant increase in pain threshold as measured by the referred pressure pain threshold (RPPT) and had a significant increase in cervical range of motion compared to the placebo group. These results however had a very small between group difference when looking at the 1-minute post treatment and 5-minute post treatment measurements. Ardiç et al.(1) performed a study that compared using TENS with upper trapezius stretching, EMS with upper trapezius stretching, and a control group of just upper trapezius stretching when treating patients with myofascial trigger points of the upper trapezius muscle. They discovered that the TENS treatment group had a greater pain threshold as measured by a 0-4 scale, less pain as measured by VAS, and greater cervical ROM when measured immediately after treatment. Immediately after treatment, the EMS group only had a decrease in pain as measured by the VAS. However, when looking at the 3 month post treatment scores both the EMS and TENS treatment groups decreased pain intensity and pain threshold showing that both treatments have good long term effects.
Procedure: I will be using the procedure that was followed in the study by Ardiç et al.(1) I will be using the TENS group procedure, but I will not be using the stretching exercises since I am just targeting the patient’s pain, not flexibility. A portable TENS machine will be used with a symmetric biphasic current, using rectangular pulses with a pulse duration of 100 microseconds, current frequency of 60 Hz, and intensity as high as the patient will tolerate. The negative electrode will be placed on the active myofascial trigger point of the upper trapezius and the positive electrode will be placed on the insertion site of the acromial tendon. The TENS will be administered for 20 minutes per day for two weeks.
Outcomes: Many outcomes were used in the studies, but for this patient I will use the visual analog scale (VAS) for their pain intensity and referred pressure pain threshold (RPPT) over the myofascial trigger point in the upper trapezius as measured using a mechanical pressure algometer. These two outcomes will allow me to get two different measurements of pain perceived by the patient. The outcomes will be assessed at the initial assessment, after one week of treatments, and at the end of the two weeks of treatment.
References:
1. Ardiç F, Sarhus M, Topuz O. Comparison of two different techniques of electrotherapy on myofascial pain. J Back Musculoskelet Rehabil. 2002;16(1):11.
2. Hsueh TC, Cheng PT, Kuan TS, Hong CZ. The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points. Am J Phys Med Rehabil Assoc Acad Physiatr. 1997;76(6):471-476.
3. Rodríguez-Fernández ÁL, Garrido-Santofimia V, Güeita-Rodríguez J, Fernández-de-las-Peñas C. Effects of Burst-Type Transcutaneous Electrical Nerve Stimulation on Cervical Range of Motion and Latent Myofascial Trigger Point Pain Sensitivity. Arch Phys Med Rehabil. 2011;92(9):1353-1358. doi:10.1016/j.apmr.2011.04.010.