‘Manual Therapy (1997) 202) 87-90 (© 1997 Pearson Professional Lid Original article Inter-therapist reliability in locating latent myofascial trigger points using palpation P.C. Lew, J. Lewis, Story School of Physiotherapy, Parkville, Australia; School of Physiotherapy, Assaf Harofed Hospital, Israel SUMMARY. Myofascial trigger points (TPs) are sites in muscle or fascia which are tender to palpate and are located in a taut band of tissue. The significance of TPs is underlined by claims that treatment applied to TPs can be effective in treating pain. Before such claims ean be validated, the ability of clinicians to identify these points reliably using palpation needs to be established, The lovation of such sites is also important for studies which try to determine the relationship of these points to other measures of pathology, e.g. EMG and thermo- graphic abnormalities. Intertester relia the localization of these points, therefore, appears to be of pri- mary importance. This study examined the concordance between two experienced clinicians in being able to identify TPs in the upper trapezius muscle. The results indicated that the agreement between these ins in identifying ‘TPs in asymptomatic subjects was poor. There was a lack of concordance not only in the Jocation of sites of ‘TPs but also in the numbers of TPs identified. This outcome challenges claims that TPs can be reliably identi- fled using palpation. INTRODUCTION has a specific pattern of pain referral which is relatively ‘constant but it does not follow a dermatomal pattern or Local or referred pain arising from muscles was demon- nerve root distltution (Bonica 1957; Travell & Simons sirated more than 50 years ago by Kellgren’s (1938) 1983). Patients” pain may be caused by many TPs, their studies. The term ‘myofascial pain syndrome’ was patterns of pain referral may overlap ar each site of introduced by Travell & Rinzler (1952) and the concept referral comprise a portion of the overall pain pattern expanded in Travell & Simons’ more recent publication Although Travell & Simons (1983) have published the (1983), Myofascial pain syndrome is a regional muscle sites of TP in various muscles (manually determined), pain disorder that is characterized by tender spots in taut they claimed that TPs can occur anywhere in the ‘bands of muscle that refer pain to areas overlying or muscle, They advocated that clinicians should become distant to the tenderness, These taut bands have been familiar with the technique of palpating for the presence described as cord like end can range in diameter from of a taut band. Two types of TPs have been classified, 1-4 mm (Travell & Simons 1983). When a taut band is active and latent (Travell & Simons 1983; Fricton et al identified by palpation, itis explored along its length to 1985). Active TPs (ATPs) cause pain and they can vary locate the spot of maximum tenderness in response to in irritability from hour to hour and from day to day. A minimum pressure, These spots are termed myofascial latent TP (LTP) does not cause pain but is tender on tigger points (TPs) and are considered to be abnormal. palpation, Furthermore it may have all the other clinical Palpation for TP is required to confirm which muscles characteristics of an ATP. Clinicai opinion is that LTPs are responsible for the myofascial pain. Each TP area predispose a person to acute attacks of pain and that normal muscles do not have taut bands of muscle fibres (Bonica 1957; Travell & Simons 1983). Nanpalae Thea ie Scat of Pier, Caer f Myofascial trigger points are important because Manipulate Tea. MSc, School of Physiotherapy, Univety there are claims that shey can be used for treating pain (Phos osgraduateDplomain Spore Paysomenyy. foseratuste Different treatment regimens have been used including Diploma'n Manipave Prywtherapy, Shoal of Pasiotheap, dry needling (Ingber 1989), injections of a variety of ‘Acta Hare Host: an story, BBS, PhD Sool Posiohcrapy, The Univensty o Melwure Pokies Australia 3052, Substances (Garvey etal 1989; Janssens 1991), transcu- ‘Comespondence to PL taneous electrical nerve stimulation (Graff-Radford et al8 Manual Therapy 1989), passive stretching (Jaeger & Reeves 1986) and laser (Snycler-Mackler et al 1989). Some studies have investigated the relationship between TPs and other measures of pathology, for example twitch response (Dexter & Simons 1981; Fricion et al 1985), EMG variations (Durete et al 1991; Hubbard & Berkof! 1993) and thermographic abnormali- ties (Fischer 1981; Kruse & Christiansen 1992; Swerdlow & Dieter 1992), The results were unforu- nately equivocal. These studies however are predicated ‘onthe ability of clinicians to reliably identify such points ‘Two studies reported poor intertester reliability in identification of TPs in patients (Nice et al 1992; Wolfe et al 1992). The aim of the study by Wolfe et al was to compare the number of TPs detected in two groups of patients (one group with fibromyalgia and the other with ‘myofascial pain) with those of a control group. In addi- tion, the study intended to compare the findings of four rheumatologists with those of four TP ‘experts’ It was notable thatthe rheumatologists were unable to become sufficiently proficient in the identification of TPs daring the study. This emphasizes that speciatist raining on TPS is critical. Nie etal (1992) found poor inter-physiother- apist reliability in assessing the presence or absence of ‘TPs at three anatomically defined sites on 50 low back pain patients. Unfortunately, most oftheir examiners did not have specialist TP training. Therefore, the lack of reliability may have been due to lack of traning. A third study examining the inter-tester reliability of ‘TP symptoms (Njoo & Van der Does 1994) found that reliability t0 assess localized tendemess, jump sign (exclamatory or withdrawal response) and patients’ recognition oftheir pain had a high kappa value. There was «low kappa value for referred pain, palpable band and twitch sign (transient muscle contraction). Unfortunately, like the Nice study, the assessors were not comparably trained. Four of the assessors were medical students, ‘The reliability of examiners to identify the location ‘of TPy tased on their palpatory assessment was not ‘evaluated by any of the studies. Furthermore, no study revealed whether clinicians with similar training might be capable of reliably locating TP using palpation techniques. ‘The aim inthis study was to determine the reliability of two clinicians with similar training in locating LTPs using palpation. In order to eliminate possible bias pain symptoms, LTP detection was investigated in favour of ATP detection, METHOD Subjects ‘There were 58 volunteers (34 females aged 18-55 years, X=28.7 years, 24 males aged 21-41 years, x= 28.9). None had received treatment to their cervical, thoracic or shoulder regions in the preceding 3 months. After reading a brief synopsis of the test procedure, all partici- pants signed an informed consent form, This study was approved by the La Trobe University Human Research, Ethies Committe. Examiners cians with special interest in soft tissues and ‘TPs were invited to participate in this study. Both were trained at the same institutions in both physiotherapy ‘and osteopathy and are regarded as TP experts by their peers. To help confirm uniformity of technique and nomen- lature, each clinician was instructed to read Chapter 6, pages 183-201 in Travell & Simons’ text (1983), which deals with the palpation position, usual trigger point location and methods of palpation for TPs in trapezius muscle, ‘The clinicians discussed the procedures, between themselves and agreed that their technique on assessing LTPs on trapezius muscle was the same as that described in Travell & Simons (1983). The clinicians ‘were instructed to palpate for LTPs by examining the traperius muscle from the spine of the scapula to its ‘upper attachments on the superior nuchal line, LTPs ‘were identified as the point in a palpable taut band within the muscle that upon compression produced maximal local and/or referred pain. Test site Only one muscle was used to minimize the time required for assessment and possible confusion between different muscles. Upper trapezius was chosen for two reasons. It was oped that being a superficial muscle \with identifiable borders that this would made the task ipler than having to palpate deeper or less well defined muscles. The second reason related to the claims of Sola etal (1955) and Travell & Simons (1983) that the trapezius muscle more frequently contains TPs. than other muscles, It was considered that this would assist the clinicians by maximizing the possibility of locating LTPs. Procedure An assistant randomly assigned the subjects to either clinician A or clinician B. In accordance with Travell & ‘Simons (1983) the subject lay prone on the examination table with the arms at rest by the side and the trapezius muscle exposed. The clinician palpated the designated area of trapezius. If a taut band of tissue was palpated that was thought to be a LTP the clinician asked the sub- ject if any local or referred tenderness was experienced, Upto this point the subjects were instructed not to speak with the clinician. If local or referred tendemess was. reported the clinician used subject feedback to locate the point of maximal tenderness and again inquired as towhether the sensation experienced was local or referred. ‘The clinician then directed the assistant to mark the loca- tion of the LTP using a cross on the body chart. The pro- cedure was then repeated ina separate examination room by the other clinician, AC least 5 minutes were allowed between the two examinations (0 allow any observable erythema from the first palpatory examination to subside. ‘The examination schedule was organized so that an average of fifteen subjects were examined in each hour session. A break of 30 minutes was allocated atthe end of each hour to provide for any delays and to allow the clinicians time to rest Body charts Quarter life size body charts were drawn in such a way that each vertebral level, the outline of the scapula, including the spine of the scapula and borders of trapez~ ius were clearly presented so as to simplify the record- ing of the location, Criteria for agreement between therapists Agreement was defined as a discrepancy of less than ‘5mm between the centre ofthe respective crosses on the charts when superimposed. The 5mm difference on the cchart, approximately equal to a 2cm difference on an average adult body, was chosen on the basis of Fricton et al’s (1985) EMG study of trapezius trigger points. Fricton etal (1985) estimated that the effect of a TP may have a radius of Lem, because EMG changes were detected within 1 em of the center of a trapezius trigger point. Although a more recent EMG study of TPs (Hubbard & Berkoff 1993) claimed that a distance of as lite as 1mm away from the TP would be enough to miss the change in EMG activity, it was decided to double the distance indicated by Fricton et al (1985) to 2cm or Smm on the chart. This seemed a generous allowance for the determination of agreement given the size of LTP and possible error of transcription. RESULTS No LTPs (referring or non-referring) were detected by either clinician in six of the 58 asymptomatic subjects. ‘Ten of the subjects for whom one clinician determined to have no LTPs were determined by the other clinician to have one or more LTPs. There were 42 subjects for ‘whom both clinicians found LTPs. However, in only ‘wo of these 42 subjects was there agreement upon the location of all LTPs. Each of these subjects had one LTP. Therefore, there was no total concordance on the loca- tion of LTPs in any subject that had more than one LTP. The results showing the comparison between clini- cians are summarized in the Table. Overall, clinician & found 133 non-referring LTPs and clinician B located 52. Of these, 151 were not agreed upon and only 17 Inertherapist reliability 89 ‘Table Inter-therapst agreement in the location of LTP Clinician A Non refering Referring Diagnosis Miss LIP. LTP Tou Miss usm 1a No MT 1 2 refering Clinician LTP B Refering 21 1 a LTP Tol 558 29 were found in common. Clinician A alse found 41 LTPs which reproduced referred pain and clinician B located 35. The location of 50 of these points were not agreed ‘upon and 13 were found in common. Thus the concor- dance for the location of non-referring LTPs was only 10% and that for referring LTPs was 21%. The empty cell reflects the unknown number of LTPs which were missed by both clinicians. The presence of this null cell ‘means that conventional measures of nominal agree- ‘ment, such as Cohen’s Kappa statistic, cannot be validly calculated, The high numbers off the diagonal repre- senting agreement are strongly indicative of a very iow level of agreement between the clinicians on the Toca- tion of LTPs, DISCUSSION ‘The results of this study indicate that the agreement between these clinicians in identifying the location of LTPs by palpating for a taut band was poor despite every effort to optimize the likelihood of agreement. ‘This was not due to whether a clinician palpated first or second, as the order was randomized. Even if it was, assumed that the clinician who located the fewer LTPS ‘was perfectly correct there would still be very poor agreement between these clinicians. This lack of agreement between clinicians, despite allowance for a generous margin of error for location, suggested true examiner differences rather then error associated with documentation of findings. This study generally sup- ports the conclusions of Nice et al (1992) and Wolfe et al (1992), that therapists cannot reliably determine the presence of a TP. Our results show that reliability between therapists may be even worse than that sug- ‘gested by Wolfe's study. This is because they only con- sidered the number of TPs detected rather than whether the clinicians agreed on a particular location of TP. In the study by Nice et al (1992), most of the testers were not specifically trained for TP detection and hence it is difficult to know whether this factor alone was the cause of the poor reliability. Similarly in90 Manuat Therapy the study by Njoo & Van der Does (1994), most of the testers Were medical students, and it would be difficult without further substantiation to be confident about their competence in palpation. In this study the researchers tried to maich the testers for their level of expert training in'TP detection. ‘There ate several possible reasons for the poor ‘agreement found in this current study between TP experts in locating LTPs. Latent myofascial trigger points had to be identified within a taut band in the muscle. It is possible that, since TP experts could not consistently identify LTPS within a taut band in the muscle, either the LTPs or the taut band may not exis. ‘This explanation would seem unlikely, aS so many workers using different techniques on TPs have been able to relieve patients” symptoms (Iaeger & Reeves 1986; Garvey et al 1989; Grafl-Radford et al 1989; Ingber 1989: Snyder-Mackler et al 1989; Janssens 1991), Another explanation might be that, regardless of how well they were applied, the palpation techniques ‘employed were simply inadequate for consistent identi fication of these points. A third explanation (and one that the authors’ favour) is that, despite verbal and jsual agreement about the definition of and the tech- nique required to palpate for LTP, the experts’ tactile perception of what constitutes a taut band may differ. If this were true, then it has direct ramifications for the teaching of palpatory techniques, because it implies that acquisition of tactile perception may not be ade- ‘quately facilitated by verbal and. visual instructions, ‘The methods employed in this study (use of text books ‘and discussion) may not have been adequate to stan- dardize the palpatory techniques employed by the examiners. OF interest, pressure algometry to detect sensitivity of trigger points may be useful when the positon of the trigger point has been located, but may bbe too laborious if an entire muscle had to be explored. ‘The outcome of this research challenges cla LTPs can be reliably identified using palpation. I posed either that clinicians vary in their understanding ‘of what constitutes a LTPs or that the palpation tech- niques used are inadequate o consistently identify these points. As these studies were performed on LTP, itis formally possible that better reliability may be found for ATPs, However, it would difficult to determine how much influence the pain pattern (cf the findings by pal- pation) might have on the assessment. Future studies should introduce rigorous familiarization sessions and some way of assessing that a common tactile perception of TPs has been achieved. ACKNOWLEDGEMENTS ‘We wish to acknowieige the cooperation and the valuable contribu tion of the cinicians who took part in this study. Our thanks also extend tothe physiotherapists who ated a assists. "We would also ike to thank the volunteers for their cooperation snd their generosity in donating thee time, “This study was undertaken as partial ffilment forthe second author's Graduate Diploma in Manipulative Physiotherapy at La ‘Trobe University Viewria. 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