PROF.

JOHN ZELJKO SRBELY (Orcid ID : 0000-0002-7455-8811)

Accepted Article
Article type : Original Manuscript

Title Page/Author Information:

The Relationship Between Rate of Algometer Application and Pain Pressure Threshold in the
Assessment of Myofascial Trigger Point Sensitivity

Linde LD, Kumbhare DA, Joshi M, Srbely JZ

Lukas Linde, MSc (Corresponding Author)

PhD Candidate
Department of Human Health and Nutritional Sciences
University of Guelph, Guelph, Ontario, N1G 2W1
Guelph: +519.824.4120 ext. 52058/fax. +519.763.5902
llinde@uoguelph.ca

Dr. Dinesh Kumbhare, MD, MSc, FRCPC

Associate Professor
Department of Medicine
Division of Physical Medicine and Rehabilitation
Toronto Rehabilitation Institute
University of Toronto
Toronto, Ontario

Maneil Joshi
Research Assistant
School of Human Kinetics
University of Ottawa
Ottawa, Ontario

Dr. John Srbely, DC, PhD

Assistant Professor
Department of Human Health and Nutritional Sciences
University of Guelph
Guelph, Ontario

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/papr.12597

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 No Funding Sources to Disclose/Acknowledge.
Accepted Article
Abstract:

Background: Pressure algometry is a commonly employed technique in the assessment of

both regional and widespread musculoskeletal pain. Despite its acceptance amongst

clinicians and scientists, the relationship between rate of pressure application (RoA) and pain

pressure threshold (PPT) remains poorly understood. We set out to test the hypothesis that a

strong, positive, linear relationship exists between the RoA and the PPT within the

infraspinatus of young healthy subjects.

Methods: Thirty-three (n=33) participants were randomly recruited from the local university

community. PPT measures were recorded from a clinically identified myofascial trigger point

(MTrP) within the right infraspinatus muscle during pressure algometry. A total of two PPT

measures were recorded using each of three different RoA including low (15N/s), medium

(35N/s), and high (55N/s). Three baseline trials were also conducted at 30N/s. The Pearson’s

correlation coefficient (R) between RoA and PPT was calculated for each subject and

averaged across participants.

Results: The mean correlation between subjects was 0.77(0.19) and the average slope of the

linear regression was 0.13(0.09).

Conclusion: Our results demonstrate that there is a strong, linear relationship between the

RoA and PPT when using the pressure algometry technique. The low slope between RoA and

PPT suggests clinicians can rely on PPT assessments despite small RoA fluctuations. Future

research should explore this relationship further in a clinical population and in other muscles

affected by chronic myofascial pain. Advancing cost effective, reliable, and clinically feasible

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 tools such as algometry is important to enhancing the diagnosis and management of chronic
Accepted Article myofascial pain.

Keywords: Pain Pressure Threshold, Pressure Algometry, Rate of Application, Myofascial

Trigger Point

Introduction:

Pressure algometry is a commonly employed technique in the assessment of both

regional and widespread musculoskeletal pain, including myofascial pain syndrome (MPS)

and fibromyalgia (FM)1. The prevalence of these conditions is high, with FM reported to

affect an estimated 2% of the population in the United States1,2. Limited data on the

prevalence of MPS exists, owing to the inconsistency in its diagnosis and classification1,3. One

source reports that it may account for up to 85% of visits to chronic pain centers4. The largest

challenge in assessing these conditions is the absence of a standardized, objective set of

diagnostic criteria1,5,6. The need to advance validated and clinically feasible assessment tools,

such as pressure algometry, is essential to the reliable diagnosis and effective management

of these musculoskeletal pain conditions.

Diagnosis of MPS and FM is often predicated on the Pain Pressure Threshold (PPT)

measured over myofascial trigger points (MTrP) or tender points respectively1. The PPT is

determined by applying an algometer, or force gauge, against a region of interest until the

participant or patient identifies a change in sensation from pressure to pain7,8,9. A key,

potentially confounding factor, in this assessment is the rate of application (RoA) of the

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 algometer over the trigger point, yet there is very limited research in this area. Only two
Accepted Article previous studies have shown strong positive associations between RoA and PPT and these

studies were limited to PPT values recorded from the oral mucosa10 and the masseter and

temporalis muscle bellies9. No studies have investigated the impact of RoA on PPT in

myofascial trigger points located within muscles commonly affected by myofascial pain.

The purpose of the present study was to determine the association between RoA and

the PPT outcome during the algometric assessment of a clinically identified myofascial trigger

point locus within a muscle commonly affected by MPS. We set out to test the hypothesis

that a strong positive, linear relationship exists between the RoA and the PPT outcome during

algometry of a MTrP locus within the infraspinatus in young healthy subjects. The findings of

this study provide important foundational data needed to advance the technique of

algometry for the reliable evaluation of musculoskeletal pain in both clinical and research

settings.

Materials and Methods:

2.1 Participants:

A total of thirty-three (n=33) young healthy adults were randomly recruited from the

local university community (Table 1). All study protocols were approved by the university

research ethics board and were conducted according to the Code of Ethics of the World

Medical Association (Declaration of Helsinki, 2000) for experiments involving humans. All

participants provided informed consent prior to participating. Each potential participant

completed a health history questionnaire and underwent a brief clinical orthopedic

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 assessment of the neck and spine to identify exclusionary criteria which could potentially
Accepted Article impact normal somatosensory processing in the cervicothoracic spine, including acute

neck/shoulder injuries, facet irritation or neurological disorders. Subject inclusion was based

on the identification of a MTrP locus within in the right infraspinatus muscle using the

accepted diagnostic criteria of a taut, palpable and tender nodule during manual palpation1.

The location of the trigger point was marked with a non-toxic marker to ensure consistent

identification of the trigger point locus throughout the trial. The same experimenter, with

over 20 years of clinical experience assessing and treating MPS, identified the myofascial

trigger point as well as performing all physical examinations.

2.2 Equipment:

PPT measurements were recorded by the same experimenter, using a pressure

algometer (Chatillon DFE, Ametek, Florida, USA) with a 3-cm2 hard foam tip11 to provide blunt

ended pressure in the assessment of myofascial trigger points12. Real-time PPT force data

was displayed throughout the trial using a custom-designed Labview program (National

Instruments Corporation, Texas, USA). This was to ensure that the experimenter was able to

accurately control the RoA (N/s) using real-time visual feedback. PPT Force data was sampled

at 100Hz. An electronic wired hand-held remote with a single button activation was held by

participants throughout the trial and participants were instructed to press the button at the

moment they felt the sensation over the trigger point change from pressure to pain. This

activated a sound to alert the experimenter to cease pressure application and the

instantaneous PPT force reading was recorded for post-hoc analysis.

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Accepted Article
2.3 Procedures:

Participants were asked to lay prone on a physiotherapy table for the duration of all

PPT assessments. All PPT assessments were performed over a MTrP site within the right

infraspinatus muscle while holding the wired remote in their left hand throughout the trial.

All MTrP loci were clinically identified by the same experimenter with over 20 years in the

diagnosis and management of chronic musculoskeletal pain. The pressure algometer was

aligned perpendicularly on the skin over the clinically identified MTrP site while pressure was

consistently applied downward onto the MTrP site. Participants were instructed to press the

hand-held button at the instant the sensation of pressure became painful.

Three baseline trials were completed to familiarize participants with the protocol. The

RoA for baseline trials was maintained at 30 N/s. Following the baseline trials, an additional 6

trials were completed consisting of two trials each using a low (15 N/s), medium (35 N/s) and

high (55 N/s) RoA. A minimum 10-second rest period was given between each trial. All rates

were maintained by the experimenter using realtime visual feedback and the order of the 6

rate variable trials was randomized using a computer generated randomization. Subjects

were blinded to the RoA. The range of RoA employed in the present study was larger than

previous studies9,10 to ensure that we tested the full spectrum of RoA values on PPT

outcomes.

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 2.4 Data and Statistical Analysis:
Accepted Article
All data was analyzed offline using a customized Matlab program (Version 2014b,

Mathworks, Natic, MA, USA). The PPT measurement at the moment the button was pressed

was used as the primary outcome for each trial. The RoA was calculated based on the slope

of the PPT force tracing from the moment of onset (value above 2N) until the button was

pressed. The consistency of the RoA was determined as the linear regression R2 value of the

PPT tracing from onset to button press. Values with an R2 less than 0.90 were removed to

ensure only PPT data from consistent RoA trials were used in the analysis.

The Pearson’s correlation coefficient between RoA and PPT was calculated for each

individual participant’s rate trials. A linear regression between RoA and PPT was performed

for each of the individual participant’s rate trials with the slope and Y-intercept reported. All

statistical analysis was completed in SPSS (SPSS Inc. Released 2013, IBM SPSS Statistics for

Windows, Version 22, Armonk, NY IBM Corp.).

Results:

The RoA throughout the trials was very consistent both within and between

participants. A total of 198 PPT trials were performed and, of these, only 4 trials were

excluded due to an R2 value below 0.90 for the rate of application, leaving 194 trials for

analysis.

The Pearson’s correlation between RoA and PPT showed a strong positive, linear

relationship (0.78±0.19) (Figure 1, Table 2, and Table 3). The slope of the linear regressions

across all participants was low (0.13±0.09) (Figure 2, Table 2, and Table 3).

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 Discussion:
Accepted Article
The results of our study support our hypothesis that a significant, positive linear

relationship exists between RoA and PPT outcome during pressure algometry of the

infraspinatus muscle. This study is the first to examine the relationship between RoA and PPT

during the algometric assessment of MTrP and our data demonstrates a significant

correlation (0.78±0.19) (Figure 1, Table 2, and Table 3) between the RoA and the PPT value in

young healthy adults. Our methodology is also the first to employ a correlation analysis of the

RoA between trials in order to ensure the consistency and reliability of RoA values

throughout our testing protocol. Our observation of a strong correlation between RoA and

PPT is in line with previous literature that has similarly reported positive linear relationships

between PPT and RoA in the orofacial tissues9,10. List et al. (1991)9 reported a correlation

coefficient of 0.70; in contrast, Ogimoto et al. (2002)10 reported a correlation coefficient of

0.99. The slight differences in correlation between our data and these previous studies may

be due to the location of PPT testing. Additionally, our data was sampled across a larger

range of RoA (7.6-175 N/s, or approximately 0.26-5.95 kg/cm2/s) in comparison to both List

(0.5 – 2.8 kg/cm2/s, or approximately 4.9 – 27.44 N/s.)9 and Ogimoto (50-225g/s, or

approximately 0.5 – 2.21 N/s)10. Furthermore, Ogimoto’s correlation was calculated on the

mean values of each of their five applied rates; in comparison we calculated across all

sampled data points10.

While the present data support the existence of strong, positive relationships

between RoA and PPT, the clinical relevance of this relationship is still poorly understood.

Although our data demonstrates a strong association between RoA and PPT, it also

demonstrates a weak effect of RoA on PPT (slope, 0.13±0.09) (Figure 2, Table 2, and Table 3).

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 Previous authors have suggested that regional differences of 20N are required for
Accepted Article differentiation between painful and asymptomatic sites8,13. Given our findings, a very

significant RoA difference of 166.7 N/s (based on the mean slope of 0.13 (Figure 2)) would be

necessary to evoke a 20N difference in PPT readings. While this suggests that RoA may not

have a clinically meaningful impact on PPT, we observed significant variability in our data.

Within the large range of slopes reported, the maximum value of 0.52 still suggests relatively

large changes in RoA are required to induce clinically meaningful differences in PPT (Table 2,

Table 3). Future studies should aim to advancing our understanding of the important

question of clinical significance of RoA on PPT.

Limitations

The results of this study should be interpreted in light of the following limitations. A

number of variables may contribute to the clinical manifestation of the PPT reading.

Subcutaneous tissue thickness and depth of the palpated trigger point may potentially

contribute to variability in the raw PPT measure between subjects. We aimed to mitigate this

effect by using the infraspinatus muscle, which is superficial and easily accessible via

palpation. It is also possible that differences in PPT may have been exaggerated with the

higher RoA we employed in this study. This may be due to a delayed reaction time of

participants in activating the hand-held trigger at the perceived PPT threshold during higher

RoA, potentially leading to an overshoot of the true PPT value. This phenomenon may be an

important consideration in the advancement of algometry technique and future research

should establish threshold RoA values to preclude this effect.

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 Finally, the current findings are limited to the assessment of myofascial trigger points
Accepted Article within the infraspinatus muscle of otherwise young healthy subjects. The primary aim of this

study was to investigate the relationship between PPT and RoA in a young healthy sample,

providing novel insight into our understanding of this relationship under normal healthy

conditions and free of comorbidities. Future research is needed to understand if a similar

association exists between RoA and PPT in chronic musculoskeletal pain populations as well

as in other muscles commonly affected by chronic musculoskeletal pain such as lumbar and

pelvis.

Conclusion:

Pressure algometry is a commonly employed tool used to quantify the pressure

sensitivity of MTrP. Despite its acceptance amongst both the clinical and research

community, the effect of RoA on the PPT measure is still poorly understood. Ours is the first

study to directly examine this relationship within the infraspinatus muscle, a commonly

affected muscle in the clinical manifestation of chronic myofascial pain. Our study

demonstrates that a significant, positive relationship exists between the RoA and the PPT in

the algometric assessment of myofascial trigger points in young healthy subjects. The low

slope of the strong relationship between RoA and PPT is clinically meaningful. Clinicians

should be confident in PPT outcomes despite small fluctuations in RoA during an algometry

assessment. Future research should explore this relationship further in a clinical population

and in other muscles commonly affected by chronic myofascial pain, including the spine and

pelvis. Given the prevalence of chronic myofascial pain and the need for a clinically reliable

and feasible tool to quantify pressure sensitivity in affected muscles, further research in this

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 field is urgently needed to advance our understanding of these relationships and enable the
Accepted Article reliable and effective clinical diagnosis and management of chronic musculoskeletal pain.

Acknowledgements:

None.

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J Pain. 2007;23(3):278-286.

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 6. Myburgh C, Larsen AH, Hartvigsen J. A Systematic, Critical Review of Manual Palpation
Accepted Article for Identifying Myofascial Trigger Points: Evidence and Clinical Significance. Arch Phys

Med Rehabil. 2008;89(6):1169-1176.

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Accepted Article Table 1: Baseline Subject Characteristics.

N 33 (14 males)

Age (years, x ̅± SD) 21.90 ± 1.77

Height (cm, x ̅± SD) 171.33 ± 11.07

Weight (kg, x ̅± SD) 68.71 ± 12.31

Table 2: Overall relationships between rate of application (N/s) (RoA) and pain pressure
threshold (N) (PPT).

Relationship between RoA and PPT

Pearson’s Correlation Coefficient (R)

Mean ± SD 0.78±0.19

Range (Min – Max) 0.20–0.99

Slope of Linear Regression (m)

Mean ± SD 0.13±0.09

Range (Min – Max) 0.03–0.52

Intercept of Linear Regression (b)

Mean ± SD 25.39 ± 7.40

Range (Min – Max) 13.77 – 44.31

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 Table 3: Individual participant relationships between rate of application (N/s) (RoA) and pain
pressure threshold (N) (PPT).
Accepted Article
Relationship between RoA and PPT
Subject Pearson’s Correlation Slope of Linear Intercept of Linear
Number Coefficient (R) Regression (m) Regression (b)
1 0.981 0.28 18.58
2 0.915 0.12 22.33
3 0.663 0.07 34.90
4 0.630 0.09 38.10
5 0.910 0.09 21.61
6 0.780 0.26 15.52
7 0.835 0.12 17.43
8 0.998 0.15 16.06
9 0.801 0.10 23.19
10 0.836 0.22 18.17
11 0.678 0.14 20.35
12 0.202 0.03 21.54
13 0.789 0.12 21.79
14 0.957 0.12 24.59
15 0.991 0.13 36.76
16 0.884 0.52 13.78
17 0.906 0.09 31.10
18 0.644 0.07 23.14
19 0.968 0.17 24.90
20 0.962 0.17 23.91
21 0.954 0.09 32.80
22 0.791 0.13 23.63
23 0.383 0.13 26.47
24 0.371 0.09 33.82
25 0.484 0.07 23.94
26 0.769 0.09 39.70
27 0.777 0.06 27.15
28 0.949 0.17 19.46
29 0.893 0.15 18.57
30 0.877 0.07 22.33
31 0.585 0.08 30.92
32 0.745 0.09 44.31
33 0.707 0.12 26.89

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Accepted Article
Accepted Article