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Journal of Bodywork & Movement Therapies (2017) 21, 11e18

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Effect of exams period on prevalence of

Myofascial Trigger points and head posture
in undergraduate students: Repeated
measurements study
Leonid Kalichman, PT, PhD*, Natalie Bulanov, BPT,
Aryeh Friedman, BPT

Physical Therapy Department, Recanati School for Community Health Professions, Faculty of Health
Sciences at Ben-Gurion University of the Negev, Beer Sheva, Israel

Received 23 November 2015; received in revised form 14 March 2016; accepted 21 March 2016

KEYWORDS Summary Background: Myofascial Trigger points (MTrPs) may be caused or aggravated by
Myofascial trigger many factors, such as mental stress associated with exams and impaired posture.
points; Aim: To compare the prevalence and sensitivity of MTrPs, and forward head position (FHP) dur-
Forward head ing exam period vs. mid-semester among physical therapy students.
position; Methods: 39 physical therapy students were palpated for MTrPs in neck and shoulder muscles
Exams and were photographed laterally for FHP measurement during the academic semester and dur-
ing the academic examination period.
Results: The subjects showed higher prevalence of active MTrPs in the right Trapezius and Le-
vator Scapula muscles, and higher prevalence of latent MTrPs in the left Sternocleidomastoi-
deus and Levator Scapula muscles during exams, as well as a higher rate of tenderness in
suboccipital musculature.
Conclusions: Physical therapy students show greater prevalence of MTrPs during exams. The
authors recommend implementing preventative programs towards the examination period.
2016 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences,
Ben-Gurion University of the Negev, POB 653, Beer Sheva, 84105, Israel. Tel.: 972 52 2767050; fax: 972 8 6477683.
E-mail addresses:, (L. Kalichman).
1360-8592/ 2016 Elsevier Ltd. All rights reserved.
12 L. Kalichman et al.

Background global assessment-either the MTrP is present, or it is not. He

based this idea on Brunse et al. (2010) diagnosis of
Myofascial trigger points (MTrPs) are a widely prevalent musculoskeletal chest pain. In order to positively diagnose
phenomenon that has been studied extensively in recent an MTrP, at least two of the four aforementioned criteria
years (Tali et al., 2014). Travell and Simons (1983e1992) must be present, with the presence of a taut band neces-
defined MTrPs as a hyperirritable spot, usually within a sary for a positive diagnosis (Myburgh et al., 2011).
taut band of skeletal muscle or in the muscles fascia, that Studies suggest that myofascial pain may be triggered,
is painful on compression and that can give rise to char- among other causes, by mental stress. It is also assumed
acteristic referred pain, tenderness and autonomic phe- that stress and anxiety influence pain. In a study conducted
nomena (the hyperirritable spot is often within a palpable by Vedolin et al. (2009), the stress and anxiety levels were
nodule) (Travell & Simons, 1983e1992). The pathophysi- shown to be higher as the academic exam period
ology of MTrPs is not completely understood. A common approached, both in healthy subjects and in patients with
agreement is that muscle overload or direct trauma to the chronic temporomandibular joint pain, though the tempo-
muscle might lead to the development of MTrPs (Bron and romandibular joint patients reported higher stress levels
Dommerholt, 2012). The most hypothesized theory today than the healthy subjects. When pressure pain threshold
is that the MTrPs are areas of sensitized low-threshold (PPT) was measured, PPT values were lower in both groups
nociceptors (free nerve endings) combined with motor during the examination period. A different study showed
endplate dysfunction and possibly an increased leakage of similar results: The PPTs of the masticatory muscles and the
acetylcholine (Huguenin, 2004; Kuan et al., 2007; Hong and Achilles tendon were significantly lower in stressed stu-
Simons, 1998). Electrophysiological studies have demon- dents, on the exam day and the adjacent days (Michelotti
strated abnormal electrical activity near MTrPs, which is et al., 2000). Treaster et al. (2006) investigated the
described in literature as endplate noise, and is associated development of MTrPs during computer work, and
with an increased amount of acetylcholine. This amount is concluded that the visual stress caused during computer
not sufficient to create a muscle contraction, but might work increases the formation of MTrPs, especially in the
explain the taut band and the nodule in the muscle trapezius muscles.
(Huguenin, 2004). In Moraskas (Moraska and Chandler, 2009) work, an as-
MTrPs are divided into two major sub-categories: active sociation between stress and MTrPs is presented through a
and latent. Active MTrPs are associated with spontaneous massage therapy aimed for MTrPs, which resulted in
local and referred pain. They may also be associated with reduced levels of anxiety, depression and overall stress
other symptoms such as weakness, paresthesia, or tem- levels.
perature changes, whereas latent MTrPs only evoke local or Many studies have established an association between
referred pain when palpated and direct pressure is applied MTrPs and headaches such as Tension Type Headaches
to them (Travell & Simons, 1983e1992). Latent MTrPs may (TTH) and Migraine Headaches (Davidoff, 1998). A connec-
become activated by a variety of stimuli, including poor tion has also been shown between the presence of active
posture, overuse, or muscle imbalance (Travell & Simons, MTrPs and a greater intensity and longer duration of
1983e1992, Huguenin, 2004). However, both active and headache episode (Fernandez-de-Las-Penas et al., 2006a,
latent MTrPs cause loss of range of motion and weakness, b). The research group of Fernandez de las Penas
which can result in limited function (Travell & Simons, (Fernandez-de-Las-Penas et al., 2006a, b, c, d; Fernandez-
1983e1992). Shah et al. (2005) and Bron and Dommerholt de-Las-Penas et al., 2007; Fernandez-de-Las-Penas et al.,
(2012) showed that there are differences in the biochem- 2010) has conducted numerous studies regarding MTrPs in
ical concentration in the areas near active MTrPs compared cervical muscles and different types of headaches. In one
to latent MTrPs. Biochemicals associated with pain and study, authors demonstrated that both active MTrPs in the
inflammation such as bradykinin, substance P, interleukins, suboccipital muscles and forward head position (FHP)
norepinephrine and more, were significantly higher near correlate with chronic TTH (Fernandez-de-las-Penas et al.,
active MTrPs and the pH levels found near active MTrPs 2006b). In another study, he established a correspondence
were significantly lower. between active MTrPs and migraine headaches (Fernandez-
Studies have shown that MTrPs are often the cause of de-Las-Penas et al., 2006d). In both studies the majority of
symptoms among patients whose primary complaint is pain. MTrPs among the study groups were active, and all subjects
One study found that 30% of general internal medicine in the study group without active MTrPs presented latent
patients suffering from undiagnosed pain suffered from MTrPs (Fernandez-de-las-Penas et al., 2006b, d).
active MTrPs (Skootsky et al., 1989), while another study FHP is a common postural disorder, in which the cra-
found MTrPs to be the cause of head and neck pain in 55.4% niovertebral angle indicates the head on trunk positioning.
of the patients examined (Fricton et al., 1985). A small angle often appears with shortening of the cervical
According to Gerwin et al. (1997), there are a variety of extensors as well as the sternocleidomastoid (SCM)
clinical characteristics that indicate the presence of a (Grimmer-Somers et al., 2008; Fernandez-de-las-Penas
MTrP, the most prominent being: a tender point in a taut et al., 2006b). In Fernandez-de-las-Penas et al. (2006b)
band of muscle, a local twitch response (LTR) to mechani- study regarding FHP and TTH, the craniovertebral angle
cal stimulation, a pain referral pattern characteristic of was compared between a group of chronic TTH patients and
MTrPs of specific areas in each muscle, and the reproduc- matched controls. Within the chronic TTH group, the cra-
tion of the patients usual pain (Gerwin et al., 1997). niovertebral angle was smaller, and headache frequency
Myburgh et al. (2011) suggested the diagnosis should be a and duration was significantly higher (Fernandez-de-las-
Penas et al., 2006b). In a cross-sectional study of 62
Effect of exams on prevalence of trigger points and head posture 13

subjects with neck pain and 52 healthy subjects, a signifi- (BMI) was calculated as weight in kg divided by height in
cantly smaller craniovertebral angle was found in the neck meters squared) and smoking.
pain group. Moreover, the subjects with smaller cranio-
vertebral angle scored higher in Northwick Park Neck Pain Measurements
Questionnaire and Numeric Pain Rating Scale. These results
demonstrate that the severity of the FHP correlates with
Each subject was examined twice: once during the semes-
functional disabilities and neck pain (Yip et al., 2008).
ter, then again during the exams period, or vice versa.
Another study showed that as the FHP severity increases, a
About alf of the sample (N Z 20) was evaluated first time
decrease in cervical joint position sense was found,
during the semester and second time during the exams
implying a connection between FHP and proprioception
period, another half (N Z 19) were evaluated in an oposit
(Lee et al., 2014).
order. Examiners during the second evaluation were blin-
University students preparing for exams are exposed to a
ded to the results of the first examination. Before each
wide variety of predisposing factors for MTrPs, mainly
measurement the subjects filled in a subjective numeric
prolonged sitting, prolonged use of computers, mental
rating scale (NRS) evaluating stress level, head and neck
concentration, reading papers, and psychological stress
pain, as well as a widely used 14 item Perceived Stress Scale
which can result in FHP and MTrPs (Treaster et al., 2006;
(PSS) questionnaire. The Alpha Cronbach reliability of the
Hoyle et al., 2011). Shahidi et al. (2013) demonstrated
Hebrew version is 79 (Cohen et al., 1983). The examination
that circumstances that require high mental concentration
included assessment of MTrPs in the cervical musculature
correlate with high stress levels and high trapezius muscle
and tenderness of the suboccipital muscles, while testing
activity. The same study also showed that the FHP became
the PPT in the MTrPs discovered.
worse during mental concentration (Shahidi et al., 2013).
The aim of the study was to compare the prevalence and
sensitivity of MTrPs and forward head position (FHP) during Outcome measures
exam period vs. mid-semester in physical therapy students.
FHP evaluation
Methods FHP is defined by the angle between the line connecting the
two markers and a horizontal line drawn from the cervical
marker. A computer program (MB Ruler) was used to
Design calculate the angle. This is the most common method for
sagittal plane posture assessment today, and it has also
Repeated measurements study with no intervention. been suggested that due to the natural postural sway it is
more reliable to measure the angle while sitting, rather
Setting than upright (Grimmer-Somers et al., 2008). FHP was
examined through a lateral photograph, with one marker
Department of Physical Therapy, Recanati School for placed on the tragus of the left ear and one on the spinous
Community Health Professions, Faculty of Health Sciences, process of C7 vertebra (Grimmer-Somers et al., 2008).
Ben Gurion University of the Negev, Beer Sheva, Israel.
MTrP evaluation
Sample MTrP diagnosis relies mainly on manual evaluation due to
lack of established reliable imaging or laboratory tech-
41 students were recruited for the study, of which 39 stu- niques. There is no gold standard for diagnosis of MTrPs to
dents participated in both measurements and two only in which manual palpation can be compared (Bron et al.,
the first measurement. Participation was voluntary and 2007; Huguenin, 2004). Wytra _
zek et al. (2015) study
students were not compensated for their time. aimed to correlate palpatory findings with algometric
measurements and surface electromyography (sEMG) re-
Inclusion criteria cordings in neck and shoulder girdle muscles. Seventy vol-
unteers were palpated bilaterally in four different shoulder
muscles, and were examined by sEMG. The study showed
physical therapy students, males and females, 20e30 years
that palpation findings correspond with sEMG recordings
and algometry measurements, which lead to a conclusion
that palpation may be regarded as an objective instru-
Exclusion criteria mental method.
Before the beginning of the current study, both exam-
significant neck or head injury in the past three years; iners (senior year physical therapy students A.F. and N.B.)
active neurological disorder; mental disorders; significant underwent training in finding MTrPs, led by an experienced
scoliosis or kyphosis. instructor in myofascial pain evaluation and treatment
(L.K.). During the training, they practiced palpation skills,
Data collection rehearsed the surface anatomy of relevant areas, discussed
technique, amount of pressure and subjects position and
Basic demographic data were collected using a self- prepared a detailed protocol of MTrPs evaluation.
administered questionnaire and include age, sex, self- The Upper Trapezius, Levator Scapula, and SCM muscles
reported weight and height (from which Body Mass Index were examined bilaterally for MTrPs. Two examiners who
14 L. Kalichman et al.

classified the results as active MTrP, latent MTrP, tight semester and those evaluated first during the exams
band, or no MTrP performed the examination separately. To period.
define an MTrP, the examiners palpated the muscles in In addition, the results of the muscles palpation findings
search of a taut band in the muscle, within which they were ranked as ordinal variables (0-no findings, 1-tight
looked for a nodule. If a nodule was located, the examiner band, 2-latent MTrP and 3-active MTrP). These findings
pressed the nodule for few seconds and asked the subject were compared (semester vs. exams) using Wilcoxon Signed
whether it evoked pain. If the subject responded nega- Ranks Test.
tively, the findings were described as a taut band. If the
subject responded positively, he/she was asked to show
where pain was felt and whether the pain is familiar. A Results
referred and familiar pain was considered an active MTrP,
while local or referred but unfamiliar pain was considered a In this study 39 students from the physical therapy
latent MTrP. department were analyzed (Table 1). Average age:
For Upper Trapezius and SCM muscles the examiners 25.33  1.94, 30 (76.9%) of which were female. Students
used a pincer palpation technique, as suggested by Travell were recruited from three different classes: 11 (28.2%) first
and Simons (1983e1992), to find a hyperirritable spot or year students, 8 (20.5%) second year, and 20 (51.3%) third
nodule and press it against the muscle fibers. For the Le- year students. BMI was calculated based on self-reported
vator Scapula examiners used a flat palpation technique at height and weight. Mean BMI (kg/m2): 22.80  3.07
the muscles insertion to find a hyperirritable spot and (17.80e30.86). Regular physical activity was reported by 35
press it toward the underlying bone (Travell & Simons, (89.7%) students, with a mean duration (hours/week)
1983e1992). Only consistent diagnoses between exam- 4.24  2.60 (0e10).
iners were regarded as MTrPs. Subjective self-reported NRS stress level was signifi-
Once a positive diagnosis was achieved, the MTrP cantly higher during exams, scored6.21  2.20, compared
sensitivity was tested by one of the examiners by measuring to 3.72  2.61 during the semester (p < 0.001). This is
the PPT with an algometer. If multiple MTrPs were found in consistent with the PSS scores, which are also significantly
the same muscle, the examiner asked the subject to indi- higher during the exams: 2.21  0.42, compared to
cate the most irritable spot. The examiner instructed the 1.99  0.37 during the semester (t Z 3.174, p Z 0.003).
subject as following: I am going to apply pressure, tell me FHP showed no significant difference between the se-
when you feel a minimal amount of pain (in Hebrew), then mester and the exams period. The mean CV angle measured
applied pressure to the MTrP with the algometer, at a rate during semester was 48.82  5.30, and examination period
of approximately 1 kg/cm2/second. This method has been mean angle was 49.58  6.35.
shown to have high interrater and intra-rater reliability by In all studied muscles the PPT was higher during exam-
Reeves et al. (1986). ination (Table 2). However, only three muscles had statis-
tically significant differences: Right SCM, Left SCM and
Suboccipital muscle tenderness Right Levator Scapula. Subjective headache and neck pain
The suboccipital muscles were palpated by both examiners NRS was also significantly higher during examination period:
and the subjects were requested to report pain if it was Headache NRS during the semester: 1.62  2.42, during
evoked. This criteria was measured dichotomously-pain was exams: 2.87  2.82 (t Z 2.698, p Z 0.01). Neck pain NRS
either present or absent. during the semester: 1.90  2.30, during exams:
3.05  2.47 (t Z 3.283, p Z 0.002).
Ethical considerations Active MTrPs in the Right Trapzius and Right Levator
Participation in the study was voluntary. Each subject scapula muscles were significantly more prevalent during
received an explanation as to the aims of the study and the exams (p Z 0.035 and 0.014, correspondingly), as well
methods of data and signed an informed consent form. The
study was approved by the Ethics Committee of the Reca-
Table 1 Characteristics of subjects (n Z 39).
nati School for Community Health Professions.
Characteristics n (%) Mean  SD (minemax)
Statistical analysis Age (years) 25.33  1.94 (22e30)
All statistical computations were performed using the SPSS Gender (females) 30 (76.9)
17.0 for Windows (SPSS, Chicago, IL, USA). Statistical ana- BMI (kg/m2) 22.80  3.07
lyses were conducted at a 95% confidence level. A p-value (17.80e30.86)
<0.05 was considered significant. Year at university
Descriptive statistics were used to characterize the 1st 11 (28.2)
sample. To compare continuous variables (FHP, NRS stress 2nd 8 (20.5)
level and PSS, NRS headache and neck pain, and PPTs of all 3rd 20 (51.3)
studied muscles) measured during the semester vs. ones Leisure physical activity
measured during the exams period we used paired T-test. Participation 35 (89.7)
To compare (semester vs. exams) suboccipital muscles Duration (hours/week) 4.24  2.60 (0e10)
tenderness, as well as prevalence of latent and active Smoking 5 (12.8)
MTrPs (dichotomous variables) Wilcoxon Signed Ranks Test Handedness (right) 35 (89.7)
was used. We also conducted the same test separately in
BMI e body mass index; SD e standard deviation.
two sub-samples, those that evaluated first during the
Effect of exams on prevalence of trigger points and head posture 15

Table 2 The comparison between continuous measurements done during the semester and ones during exams.
Variables During semester During exams Comparison
Mean SD Mean SD t Sig. (2-tailed)
FHP 48.82 5.30 49.58 6.35 1.266 0.213
NRS stress level 3.72 2.61 6.21 2.20 5.787 0.000
PSS 1.99 0.37 2.21 0.42 3.174 0.003
NRS headache 1.62 2.42 2.87 2.82 2.698 0.010
NRS neck pain 1.90 2.30 3.05 2.47 3.283 0.002
PPT Right Trapezius 1.55 0.78 1.56 0.64 0.092 0.927
PPT Left Trapezius 1.76 0.73 1.84 0.91 0.443 0.660
PPT Right SCM 0.29 0.51 0.63 0.59 2.982 0.006
PPT Left SCM 0.19 0.44 0.52 0.62 2.553 0.016
PPT Right Levator Scapula 1.28 1.13 1.77 0.98 2.379 0.023
PPT Left Levator Scapula 1.09 0.99 1.48 0.96 1.878 0.068
FHP e forward head posture; SD e standard deviation; Sig. e significance; NRS e numeric rating scale; PPT e pressure pain threshold;
SCM e sternocleidomastoid muscle.
Statistically significant differences (p < 0.05) marked bold.

as latent MTrPs in the Left SCM and Left Levator Scapula Discussion
muscles (p Z 0.007 and 0.029, correspondingly). Sub-
occipital muscle tenderness was also significantly more The results of this study showed a greater prevalance of
prevalent during the exams (p Z 0.011). In the other MTrPs during the exam period, in correlation with the
muscles examined, no significant results were demon- studys thesis. Many studies have established a connection
strated (Table 3). The total prevalance of MTrPs, both between mental load and muscle activity, as Roman-Liu
active and latent, during the exam period was higher et al. (2013) discuss in depth in the introduction to their
compared to the semester. study. The results of their study confirm that muscle ten-
When treated as a ordinal variables, myofascial findings sion increases during sustained attention and vigilance
showed significantly higher prevalence of MTrPs in the right tests, especially in the shoulder girdle and, less signifi-
Trapezius and right SCM muscles during exams (Table 4). cantly, in the forearm (Roman-Liu et al., 2013). The re-
We calculated the power (probability) to reject the null searchers attempted to isolate the mental load from
hypothesis that this response difference between semester posture by having the study and control groups remain in
and exam period is zero for the following parameters: the same supported posture throughout the test, thus
N Z 39, type I probability Z 0.05. For all parametric tests minimizing the biomechanical load on the shoulder girdle.
the power was <0.8, meaning that our sample size was Shahidi et al. (2013) study also showed an increase in
sufficient to test our hypotheses. muscle EMG activity during high stress condition in

Table 3 The comparison between measurements done during the semester and ones during exams.
Variables During semester During exams Comparison
Yes No Yes No Za Sig. (2-tailed)
Suboccipital muscles tenderness 27 14 33 6 2.530 0.011
Active MTrPs Right Trapezius 11 30 17 22 2.111 0.035
Active MTrPs Left Trapezius 7 34 9 30 1.000 0.317
Active MTrPs Right SCM 3 38 4 35 0.447 0.655
Active MTrPs Left SCM 3 38 2 37 1.000 0.317
Active MTrPs Right Levator Scapula 2 39 7 32 2.449 0.014
Active MTrPs Left Levator Scapula 5 36 2 37 1.342 0.180
Latent MTrPs Right Trapezius 28 13 21 18 1.508 0.132
Latent MTrPs Left Trapezius 34 7 29 10 1.342 0.180
Latent MTrPs Right SCM 6 35 13 26 1.941 0.052
Latent MTrPs Left SCM 2 39 11 28 2.714 0.007
Latent MTrPs Right Levator Scapula 25 15 24 15 0.277 0.782
Latent MTrPs Left Levator Scapula 21 20 29 10 2.183 0.029
Statistically significant differences (p < 0.05) marked bold.
Result of the Wilcoxon Signed Ranks Test; Sig. e significance; SCM e sternocleidomastoid muscle.
16 L. Kalichman et al.

Table 4 Comparison between muscles palpation findings done during the semester and ones during exams (MTrPs findings
treated as ordinal variable).
Variables MTrPs evaluation Comparison
No Tight band Latent MTrPs Active MTrPs Za Sig. (2-tailed)
Right Trapezius Semester 1 1 28 11 2.111 0.035
Exams 1 0 21 17
Right SCM Semester 25 7 6 3 1.975 0.048
Exams 18 4 13 4
Right Levator Scapula Semester 13 0 26 2 1.811 0.070
Exams 8 0 24 7
Left Trapezius Semester 0 0 34 7 0.000 1.000
Exams 1 0 29 9
Left SCM Semester 31 4 3 3 1.762 0.078
Exams 21 5 11 2
Left Levator Scapula Semester 15 0 21 5 1.232 0.218
Exams 8 0 29 1
Statistically significant differences (p < 0.05) marked bold.
Result of the Wilcoxon Signed Ranks Test; Sig. e significance; SCM e sternocleidomastoid muscle.

comparison to low stress, in the Upper Trapezius muscle, The findings of these studies were a drop in the PPT values,
both in dominant and non-dominant sides. suggesting the stress condition increases the pain sensi-
In Linton (2000) review of 11 studies discussing stress tivity. However, in Michelotti et al. (2000) study it is stated
and anxiety, a significant relation was found between these that the spearman correlation between changes in PPT and
parameters and neck or back pain. This is consistent with stress, on the day of exam and a month later, were
the current studys results, in which the NRS of neck pain generally low.
was significantly higher during the exam period. It is possible that the current study is less reliable than
The hypothesis that FHP will be more pronounced during contradicting studies, as the PPT was measured only once
the exam period was repudiated. The FHP was slightly lesser at each location in the current study, whereas most other
during the semester with the mean angle measuring a mere studies involved multiple measurements with a mean or
0.76 degrees less than the mean angle during the exam maximal result (Michelotti et al., 2000; Walton et al., 2014;
period. This could be explained by Shahidi et al. (2013) Chesterton et al., 2003; Vedolin et al., 2009). On the other
study, in which subjects had to complete a computer task hand, the consistent increase in PPT during exams (in both
in low stress and in high stress conditions. the CV angle sub-samples, those that evaluated first during the semester
measured during the task was smaller compared to baseline and those evaluated first during the exams period) and the
measurements, but there was no difference between the statistically significant values of the current study suggest
lower and the higher stress conditions. In other words, the low risk of bias in PPT evaluations.
CV angle decreases during task performance and mental In the current study, suboccipital tenderness was
concentration but is not necessarily influenced by stress examined as an indication of possible MTrPs in the sub-
levels. Based on these findings, it is possible that because occipital muscles. Travell and Simons (1983e1992) wrote
students require mental concentration during the semester that actual diagnosis of MTrPs in these muscles is very
as well as during exams, the FHP results are similar during difficult, given the layers of muscles superficial to them.
the two time periods, despite the difference in stress levels. Fernandez-de-las-Penas et al. (2006b) devised an inter-
The PPT values in the current study were consistently esting method which defined modified criteria for diag-
higher during examinations than during the semester, con- nosis: the suboccipital muscles are to be palpated and
trary to the researchers hypothesis and to other studies: In compressed for 10 s with the neck in neutral position while
one study, the researchers asserted that fear and anxiety the subject is supine. If the aforementioned palpation
affect the pain threshold inversely: While fear decreases elicits pain, the subject should be instructed to extend his
pain and increases PPT values, anxiety decreases the PPT upper cervical spine by tilting his head back. If this exam-
and increases pain sensitivity (Rhudy and Meagher, 2000). ination elicits familiar pain, the MTrP is defined as active. If
According to their definition of anxiety, future-oriented the elicited pain is unfamiliar, The MTrP is be defined as
emotion characterized by negative affect and apprehensive inactive (Fernandez-de-las-Penas et al., 2006b). Regret-
anticipation of potential threats (Rhudy and Meagher, tably, this method has not been validated and was there-
2000). It would seem that students during exams fall into fore deemed irrelevant to the current study. If this method
that category, yet their results differ from the results of the will be validated, it could be a valuable diagnostic tool.
current study. Vedolin et al. (2009) and Michelotti et al.
(2000) also conducted studies with results that disagree Limitations
with the findings of the current study. Both studies found
the academic examination to be a natural stressor, and The first limitation of this study is the relative lack of
investigated the influence of stress and anxiety on the PPT. experience of the examiners. The researchers tried to
Effect of exams on prevalence of trigger points and head posture 17

minimize the possible bias by specific training, strict pro- ResearchTools/Quantitative/HebetimRigshiyim/Dahak/

tocol and double (by both examiners, blinded to results of SheelonLehaarahatDhak-PSS.pdf.pdf (accessed 01.02.15.).
each other) evaluation of MTrPs. Only consensus results Davidoff, R.A., 1998. Trigger points and myofascial pain: toward
were recorded. understanding how they affect headaches. Cephalalgia 18 (7),
Another limitation is that the examiners were not blin-
Fernandez-de-Las-Penas, C., Alonso-Blanco, C., Cuadrado, M.L.,
ded as to whether the student was in the exam period or Gerwin, R.D., Pareja, J.A., 2006a. Myofascial trigger points and
the semester, which may cause a bias. their relationship to headache clinical parameters in chronic
The results of the current study pertain to 22e30 years tension-type headache. Headache 46 (8), 1264e1272.
old university students. It is possible that individuals of Fernandez-de-las-Penas, C., Alonso-Blanco, C., Cuadrado, M.L.,
different age or education backgrounds would react Gerwin, R.D., Pareja, J.A., 2006b. Trigger points in the sub-
differently in a similar situation. occipital muscles and forward head posture in tension-type
headache. Headache 46 (3), 454e460.
Fernandez-de-Las-Penas, C., Alonso-Blanco, C., Cuadrado, M.L.,
Conclusions Pareja, J.A., 2006c. Myofascial trigger points in the suboccipital
muscles in episodic tension-type headache. Man. Ther. 11 (3),
The results of this study showed a greater number of MTrPs 225e230.
Fernandez-de-Las-Penas, C., Cuadrado, M.L., Pareja, J.A., 2007.
in cervical and shoulder girdle musculature and a higher
Myofascial trigger points, neck mobility, and forward head
neck pain NRS score during the exam period. However, no
posture in episodic tension-type headache. Headache 47 (5),
difference in FHP between two periods was established. It 662e672.
is still unclear whether the stressful nature of academic Fernandez-de-Las-Penas, C., Cuadrado, M.L., Pareja, J.A.,
examinations, a relevant threat for students, is the main 2006d. Myofascial trigger points, neck mobility and forward
cause for these findings, or the prolonged mental demand head posture in unilateral migraine. Cephalalgia 26 (9),
of preparing for the exams. This question should be further 1061e1070.
investigated. The authors suggest that a preventative pro- Fernandez-de-Las-Penas, C., Ge, H.Y., Alonso-Blanco, C., Gonza-
gram should be considered for students during their exams, lez-Iglesias, J., Arendt-Nielsen, L., 2010. Referred pain areas of
in order to minimize musculoskeletal disorders and dis- active myofascial trigger points in head, neck, and shoulder
muscles, in chronic tension type headache. J. Bodyw. Mov.
abilities in the future.
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Fricton, J.R., Kroening, R., Haley, D., Siegert, R., 1985. Myofascial
Conflict of interest statement pain syndrome of the head and neck: a review of clinical
characteristics of 164 patients. Oral Surg. Oral Med. Oral Pathol.
60 (6), 615e623.
There were no funding or financial benefits to the authors. Gerwin, R.D., Shannon, S., Hong, C.Z., Hubbard, D., Gevirtz, R.,
This paper has not been presented in the past in any form. 1997. Interrater reliability in myofascial trigger point exami-
No conflicts of interest have been reported by the authors nation. Pain 69 (1e2), 65e73.
or by any individuals in control of the content of this Grimmer-Somers, K., Milanese, S., Louw, Q., 2008. Measurement of
article. cervical posture in the sagittal plane. J. Manip. Physiol. Ther. 31
(7), 509e517.
Hong, C., Simons, D.G., 1998. Pathophysiologic and electrophysi-
Financial support ologic mechanisms of myofascial trigger points. Arch. Phys.
Med. Rehabil. 79 (7), 863e872.
None. Hoyle, J.A., Marras, W.S., Sheedy, J.E., Hart, D.E., 2011. Effects of
postural and visual stressors on myofascial trigger point devel-
opment and motor unit rotation during computer work. J.
Acknowledgments Electromyogr. Kinesiol. 21 (1), 41e48.
Huguenin, L.K., 2004. Myofascial trigger points: the current evi-
dence. Phys. Ther. Sport 5 (1), 2e12.
We would like to thank all subjects for participating in this Kuan, T.S., Hsieh, Y.L., Chen, S.M., Chen, J.T., Yen, W.C.,
study. Hong, C.Z., 2007. The myofascial trigger point region: correla-
tion between the degree of irritability and the prevalence of
endplate noise. Am. J. Phys. Med. Rehabil. 86 (3), 183e189.
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