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Pain Medicine, 21(11), 2020, 2622–2624
Advance Access Publication Date: 23 September 2020
Evidence-Based Medicine and Low Back Pain, Post-Stroke
Hemiparetic Spastic Shoulder, and Physical Exercise as Treatment of
Myofascial Pain Dysfunction
Robert D. Gerwin, MD
Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
Conflicts of interest: There are no conflicts of interest to report.
This issue of Pain Medicine features three articles that
add to the literature supporting evidence-based treatment
of musculoskeletal pain and dysfunction. The practice of
medicine has evolved over the decades so that preferred
practice is expected to be evidence based whenever possi-
ble. Evidence-based medicine requires a change in the
quality of evidence that we require in order to decide
whether or not a treatment modality is sufficiently sup-
ported by the available data [1]. The hallmark of a high-
quality study is that, when possible, it is a randomized
controlled trial (RCT) with low bias. When there are
enough RCTs available, a systematic review and meta-
analysis allows a statistically sound approach to the eval-
uation of the data [1,2]. This issue of the journal includes
two RCTs reporting different effects of dry needling
(DN) of trigger points and one systematic review and
meta-analysis of the effect of physical exercise on myo-
fascial trigger point–related dysfunction. The studies are
needed and welcome because of the importance of myo-
fascial trigger points as a cause of pain, dysfunction, and
disability and because of the relative lack of randomized
controlled studies that address the effectiveness of treat-
ment of myofascial pain by both DN and physical ther-
apy modalities. These studies highlight the strengths and
the pitfalls of studies in this area; support the use of DN
in a novel approach to low back pain treatment;
strengthen the evidence for using physical exercise (an ac-
cessible and cost-effective therapy); and explore the inter-
action between peripheral sources of nociception and
spinal motor neuron excitability in post-stroke spasticity.
The study of the treatment of low back pain by treat-
ing trigger points in the abductor muscle gluteus medius
is novel and is based on observations that impaired hip
Gerwin
doi: 10.1093/pm/pnaa324
Editorial
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abductor muscle strength and function are associated
with chronic nonspecific low back pain. Martin-Corrales
and colleagues [3], based at the Universidades de Jaen
and Alcala, Spain, treated two randomized groups, one
with DN and one with sham DN (SN). Both groups were
then treated with a gluteus medius physical exercise pro-
gram. The control group is important because an inap-
propriate control group can introduce bias that can affect
the results. Knowing that the participants were blinded
to the treatment is an added benefit to a study, eliminat-
ing one source of bias, but reporting the effectiveness of
blinding is not always done and was not reported in this
study. However, the sham needles used in this study had
previously been found to provide adequate sham treat-
ment, reducing the concern about this kind of bias. It is
important that the control group be an active treatment
group comparable with the experimental treatment
group except for the intervention to be studied, as in this
study. An inactive treatment group, such as participants
on a waiting list to be treated, introduces another bias
that can affect the results. This study is well designed in
that regard. The primary outcome—reduction in pain in-
tensity at 3 months—was significant in favor of DN over
sham needling. Secondary outcomes showed a similar im-
provement over time for both disability and fear avoid-
ance with no difference between the DN and the sham
needling groups. Pain pressure threshold (PPT) increased
significantly for DN compared with SN except for the
gluteus medius muscle at 3 months. Postneedling soreness
was present in a large proportion of participants in both
the DN and SN groups. Thus, pain relief was significant,
lasting over 3 months, even though function and disabil-
ity were not affected by DN but were improved by the
Editorial
course of exercise. This is an important study that has the
potential to contribute significantly to the management
of the intractable problem of chronic low back pain.
The second study of DN of trigger points in this issue
is from the very active group at the Universidad Rey Juan
Carlos in Madrid, Spain [4]. This study examined the ef-
fect of DN on spasticity, pain, and function in the post-
stroke chronically hemiparetic shoulder. The authors
used a crossover RCT protocol. Measurements of spastic-
ity (muscle tone) used the Modified Ashworth Scale
(MAS), measurements of function used the Motor
Evaluation Scale for Upper Extremity and the Reaching
Performance Scale, and measurements of pain used a vi-
sual analog scale. Trigger points in the upper trapezius,
anterior deltoid, and supraspinatus and infraspinatus
muscles were identified and treated by DN. Pain intensity
decreased significantly at weeks 2 and 6 following the
DN intervention. DN did not affect either spasticity
(muscle tone) or function. Prior studies by this group sug-
gested that DN can affect pressure pain sensitivity and
range of motion in the spastic limb but had variable
responses with regard to spasticity, as measured by the
MAS. This study, as well as the previous studies, is of
great interest not only because of the reduction of pain
but also because it examines a peripheral intervention,
DN of a trigger point (TrP) , that is intended to alter a
central mechanism: the disinhibition of spinal motor neu-
rons. The premise is that chronic TrPs contribute to cen-
tral hyperexcitability, affecting both motor and sensory
spinal neurons. There are a number of procedural issues
raised by this interesting study. First, is the MAS, widely
used in the physical therapy world, an appropriate test
for spasticity in assessing the effect of TrPs because TrPs
can shorten muscle and produce resistance to stretch,
which is at the bottom of what the MAS measures? The
Hmax:Mmax ratio and reciprocal inhibition, which assess
the percentage of motorneurons activated by the H-reflex
and presynaptic inhibition, respectively [5], may elimi-
nate any effect of TrP-induced muscle contraction that
might affect the MAS. A second point raised by this study
is that the effect of TrPs in a given muscle on pain or on
sensory and motor central sensitization is not quantifi-
ably related to the number of TrPs or the number of af-
fected muscles. Is the effect of TrPs on multiple muscles
additive, logarithmic, or something else? The effect of
TrPs on motor excitability is a field ripe for investigation.
It is reasonable to consider that if the goal is to assess the
effect of TrPs on spasticity that as much of the TrP load
as possible would be eliminated. It is conceivable that the
lack of effect on spasticity reported in this article reflects
inadequate elimination of TrPs in the target muscles.
One wonders if function would also be improved if all
shoulder region muscles with trigger points were treated,
not just a few. Moreover, with regard to spasticity, TrPs
are generally associated with an inhibition of tendon
reflexes, not hyperactive tendon reflexes, and with re-
duced range of motion rather than a spastic catch or
2623
clonus that is expected with disinhibition of motor neu-
rons. Hence, any effect of DN on spasticity would be
highly interesting. The clinical relevance of this study is
that the DN technique can contribute to the management
of patients with stroke-related hemiparetic shoulder spas-
ticity through the reduction of pain, if not in restoration
of function. The latter issue, however, remains to be re-
solved. This study, furthermore, addresses an interesting
problem and raises fascinating questions as to how to
study such a complicated problem as spasticity and how
to interpret the study outcomes. We anticipate further re-
search in this area from these authors, who are to be
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commended for their persistence in studying this
question.
The third article is a systematic review and meta-
analysis of the effect of physical exercise on myofascial
TrP-related dysfunction. This is important, as physical
exercise is inexpensive and accessible to most therapists
and most patients. However, it is hard to study because
exercise protocols vary, patient effort varies, and dura-
tion of treatment varies. Guzman et al. [6], from Spain
and South America, identified 24 randomized controlled
studies suitable for analysis. These studies constituted a
heterogeneous group that included (in different studies)
regions of the cervical spine, the lumbar spine, the upper
back, the shoulder, and the upper limbs. The forms of
physical exercise included stretching, aerobic and
strengthening exercises, and some types of combined
exercises. They looked at pain intensity, PPT, range of
motion, and disability. They found that physical exercise
is effective in reducing pain, lessening pressure sensitivity
(increased PPT), and improving range of motion. There
was no effect on disability. This is an important finding,
and these authors have provided a great service to the
clinical management of an important cause of musculo-
skeletal pain.
As more clinicians become aware of myofascial TrP
pain syndromes and related dysfunction, the principles of
evidence-based clinical practice demand that we identify
treatments that are effective and that we eliminate treat-
ments with limited or no effectiveness. Spain has fostered
the growth of several groups actively pursuing relevant
studies in this area. We hope that the publication of these
three studies will not only support evidence-based prac-
tice but will also encourage others to conduct similar
studies that support or do not support current and emerg-
ing therapies for musculoskeletal pain. Pain Medicine
remains committed to publishing quantified studies in
this area and actively seeks contributions from authors
working in the field of musculoskeletal and neuromuscu-
lar pain.
References
1. Djulbegovic B, Guyatt GH. Progress in evidence-based medicine:
A quarter century on. Lancet 2017;390(10092):415–23.
2624
2. Horwitz RI, Hayes-Conroy A, Caricchio R, Singer BH. From evi-
dence based medicine to medicine based evidence. Am J Med
2017;130(11):1246–50.
3. Martin-Corrales C, Bautisa I, Mendez-Mera J, et al. Benefits of
adding gluteal dry needling to a 4-weeks physical exercise pro-
gram in a chronic low back pain population. A randomized clini-
cal trial. Pain Med 2020; doi: 10.1093/pm/pnaa279.
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Changes in muscle tone, function, and pain in the chronic hemipa-
retic shoulder after dry needling within or outside trigger points in
Future Directions in Psychological Therapies for Pain Management
Asimina Lazaridou, PhD, Myrella Paschali, MD, and Robert R. Edwards, PhD
Department of Anesthesiology, Harvard Medical School, Brigham & Women’s Hospital, Chestnut Hill, Massachusetts, USA
Asimina Lazaridou and Myrella Paschali served as co–first authors and contributed equally to the work.
Psychological therapies for chronic pain are well estab-
lished and have been deployed for decades as part of em-
pirically supported interdisciplinary pain management
programs [1]. Perhaps the most venerable and frequently
encountered psychological approach to chronic pain
management is cognitive behavioral therapy (CBT),
which focuses on restructuring maladaptive cognitive
and behavioral responses to pain to promote more adap-
tive and effective self-management of pain and its adverse
impacts. Historically, CBT has not been monolithic, and
it has encompassed an array of approaches that have
shifted over time through several distinct generations,
even as CBT has remained the “gold standard” for psy-
chological interventions for pain [2]. The arrival of a
“third wave” of psychological treatments has been part
of an extension of CBT that has taken place over the past
several decades [3], based centrally on the need for new
cognitive and affective approaches that focus more on an
individual’s relationship to thoughts and emotions than
on the actual cognitive and affective content.
Collectively, third wave–based interventions are uniquely
focused on mindfulness, acceptance, diffusion, life val-
ues, and relationships [4], although some have argued
that the broad umbrella of CBT covers these concepts as
well as more traditional cognitively and behaviorally ori-
ented CBT approaches [5].
Lazaridou et al.
stroke patients: A crossover randomized clinical trial. Pain Med
2020; doi: 10.1093/pm/pnaa132.
5. Okuyama K, Kawakami M, Hiramoto M, Muraoka K, Fujiwara
T, Liu M. Relationship between spasticity and spinal neural cir-
cuits in patients with chronic hemiparetic stroke. Exp Brain Res
2018;236(1):207–13.
6. Guzman MJ, Cavero-Redondo I, Martinez V, Fernandez R, Reina
S, Alvarez Bueno C. Effect of physical exercise programs on myo-
fascial trigger points related dysfunctions: A systematic review
and meta-analysis. Pain Med 2020; doi: 10.1093/pm/pnaa253.
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Pain Medicine, 21(11), 2020, 2624–2626
doi: 10.1093/pm/pnaa335
Advance Access Publication Date: 27 October 2020
Editorial
The most researched third-wave therapies for the
treatment of chronic pain are acceptance and commit-
ment therapy (ACT) and mindfulness-based interventions
(MBIs), encompassing mindfulness-based cognitive ther-
apy and mindfulness-based stress reduction (MBSR) [6],
which were developed by Kabat-Zinn [7] and were ini-
tially used as a treatment for chronic pain in the 1980s,
along with the more recently developed emotional aware-
ness and expression therapy (EAET). Third-wave thera-
pies, which can be delivered in an individual or group
format, tend to differ from other psychological
approaches, as the focus is less on reducing or eliminating
negative cognitive or affective content (e.g., diminishing
stress and depression) and more on the acceptance of un-
pleasant experiences [8, 9]. Other emerging, empirically
supported approaches (which do not make an appear-
ance in this issue of Pain Medicine) include education-
focused approaches such as pain neuroscience education
(often referred to as “explaining pain” [EP]) and dialecti-
cal behavioral therapy (DBT). EP refers to a set of educa-
tional interventions that aim to change patients’
understanding of the biological processes that are
thought to underpin pain as a mechanism to reduce pain
itself [10]. It draws on conceptual change strategies to
help patients understand current thought in pain biology,
shifting the conceptualization of pain from that of a