Fleckenstein et al.

BMC Musculoskeletal Disorders 2010, 11:32

http://www.biomedcentral.com/1471-2474/11/32

RESEARCH ARTICLE Open Access

Discrepancy between prevalence and perceived

effectiveness of treatment methods in myofascial
pain syndrome: Results of a cross-sectional,
nationwide survey
Johannes Fleckenstein, Daniela Zaps, Linda J Rüger, Lukas Lehmeyer, Florentina Freiberg, Philip M Lang,
Dominik Irnich*

Abstract
Background: Myofascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the
general population. Current guidelines for the management of myofascial pain are not available. In this study we
investigated how physicians on the basis of prescription behaviour evaluate the effectiveness of treatment options
in their management of myofascial pain.
Methods: We conducted a cross-sectional, nationwide survey with a standardized questionnaire among 332
physicians (79.8% male, 25.6% female, 47.5 ± 9.6 years) experienced in treating patients with myofascial pain.
Recruitment of physicians took place at three German meetings of pain therapists, rheumatologists and
orthopaedists, respectively. Physicians estimated the prevalence of myofascial pain amongst patients in their
practices, stated what treatments they used routinely and then rated the perceived treatment effectiveness on a
six-point scale (with 1 being excellent). Data are expressed as mean ± standard deviation.
Results: The estimated overall prevalence of active myofascial trigger points is 46.1 ± 27.4%. Frequently prescribed
treatments are analgesics, mainly metamizol/paracetamol (91.6%), non-steroidal anti-inflammatory drugs/coxibs
(87.0%) or weak opioids (81.8%), and physical therapies, mainly manual therapy (81.1%), TENS (72.9%) or
acupuncture (60.2%). Overall effectiveness ratings for analgesics (2.9 ± 0.7) and physical therapies were moderate
(2.5 ± 0.8). Effectiveness ratings of the various treatment options between specialities were widely variant. 54.3% of
all physicians characterized the available treatment options as insufficient.
Conclusions: Myofascial pain was estimated a prevalent condition. Despite a variety of commonly prescribed
treatments, the moderate effectiveness ratings and the frequent characterizations of the available treatments as
insufficient suggest an urgent need for clinical research to establish evidence-based guidelines for the treatment of
myofascial pain syndrome.

Background Myofascial pain affects up to 85% of the general popu-

Myofascial pain syndrome is a chronic muscular pain lation [2]. Myofascial trigger points play a central role in
disorder in one muscle or groups of muscles accompa- the pathophysiology of common myofascial pain syn-
nied by local and referred pain, decreased range of dromes [3]. Myofascial trigger points are defined as
motion, weakness, and often autonomic phenomena. It hyperirritable spots, usually within a taut band of skele-
is a primary cause of health-care visits, absenteeism and tal muscle or in the muscle fascia, which is painful on
invalidity pensions [1]. compression and can give rise to characteristic referred
pain, motor dysfunction, and autonomic phenomena [2].
* Correspondence: [email protected] Moreover, abnormal spontaneous electrical activities
Multidisciplinary Pain Centre, Department of Anaesthesiology, University of have been described at these sites [4]. Several
Munich, Munich, Germany

© 2010 Fleckenstein et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Fleckenstein et al. BMC Musculoskeletal Disorders 2010, 11:32 Page 2 of 9
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biochemical and proinflammatory mediators seem to be orthopaedists and rheumatologists as they were thought
involved in these ectopic pain mechanisms [5,6] and to be the ones with most experience in attending and
were found to be significantly higher in active trigger treating myofascial pain syndrome.
points [5]. Neuroplastic remodelling has been shown in
the peripheral and central nerve system [7]. However, Ethics
the understanding of the neurophysiologic genesis of In this trial we consider the ethical, legal and regula-
trigger points and their role in myofascial pain syn- tory norms and standards for research involving
drome remains a present focus of research [8]. human subjects in Germany. As this study did not
Treatment approaches in myofascial pain range from involve patient data and the research did not involve
analgesics to various physical modalities. These humans, ethical approval was not necessary http://
approaches include combined techniques (e.g. spray and www.wma.net/en/30publications/10policies/b3/index.
stretch), manual techniques, transcutaneous electrical html. Written consent was not sought from each parti-
stimulation (TENS), frequency-modulated neural stimu- cipant for use of survey data, but consent of respon-
lation, ultrasound or massage, injections, acupuncture dents was assumed if they completed and returned the
and dry needling [9-14]. Analgesics are often used in questionnaire.
the treatment of myofascial pain [15]. Despite the vari-
ety of treatment approaches, there is a lack of clinical Questionnaire (additional file 1)
evidence to guide treatment. There is moderate evidence Demographic and participants characteristics
suggesting that back schools reduce pain in an occupa- In the first part we assessed the following demographic
tional setting and improve function and return-to-work data: age, gender, field of specialisation (surgery, internal
status [16]. Acupuncture and dry-needling may be useful medicine, anaesthesiology, neurology and orthopaedics),
adjuncts [13,17-20]. Trigger point injections remain the subspecialisation (pain therapy, rheumatology and trau-
treatment with the most scientific support [18,20,21]. matology), employment centre (university hospital,
Various injected substances have been investigated. county hospital, private clinic and pain centre), and sta-
These include local anaesthetics, botulinum toxin, sterile tus of specialisation (resident and consultant). We asked
water and sterile saline [15,17,18,21,22]. Despite, data for the physician’s average number of treated myofascial
does neither favour injection of any substance in parti- pain patients and the number of patients referred to
cular over injection of an inert substance, nor are injec- specialised pain centres.
tions (wet needling) superior to dry needling [18,20,23]. Estimated importance of myofascial pain syndrome and
The available data do explicitly not support the use of prevalence of myofascial trigger points
botulinum toxin injection in trigger points for myofas- Secondly we wanted the physicians to estimate the
cial pain [21,22]. importance of myofascial pain in the general population
In conclusion there is not sufficient clinical evidence on a six-point scale (with 1 being a very common pro-
to incorporate evidence-based guide treatments. blem). Additionally the physicians had to estimate the
We therefore evaluated the distribution of the usage prevalence of active trigger points in the population and
and physicians rating of effectiveness for frequently pre- their respective patients in percent.
scribed treatments amongst German physicians with Prescription rates and rating of treatment options
experience in treating patients with myofascial pain. Physicians were asked to choose their routinely pre-
scribed therapeutic options in the treatment of myofas-
Methods cial pain syndrome from a list of prespecified options.
Design and setting Afterwards they had to rate the effectiveness of the
We conducted a cross-sectional, nationwide survey approaches chosen based on their own experience on a
among German physicians involved in the management six-point scale (with 1 being “excellently effective” and 6
of patients with myofascial pain. Participants were being “ineffective”). We asked for analgesics (non-steroi-
recruited at the annual meetings of the German Society dal anti-inflammatory drugs/coxibs, metamizol/paraceta-
for the Study of Pain, German chapter of the IASP mol, weak and strong opioids, anticonvulsants,
[Deutsche Gesellschaft zum Studium des Schmerzes], antidepressants,), physical medicine (TENS, manual
the Professional Organisation of German Rheumatolo- therapy, ultrasound, percussion waves, acupuncture, dry
gists [Berufsverband Deutscher Rheumatologen] and the needling) and injections (spinal interventions, injection
Association of Southern German Orthopaedists [Verei- of botulinum toxin or local anaesthetics). In each cate-
nigung Süddeutscher Orthopäden]. Participants com- gory, physicians had the opportunity to name additional
pleted a standardised questionnaire. treatment approaches (free text). Finally, we asked for
A subgroup analysis was performed within three the opinion regarding the sufficiency of available treat-
groups of all physicians. We chose pain therapists, ment options.
Fleckenstein et al. BMC Musculoskeletal Disorders 2010, 11:32 Page 3 of 9
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Statistical analysis Estimated importance of myofascial pain syndrome and

All statistical analysis was carried out using the SPSS prevalence of myofascial trigger points
statistical software system (SPSS Inc., Chicago, IL; ver- When asked for the importance of myofascial pain the
sion 15.0). Data were expressed as mean ± SD. physicians mean score was 2.5 ± 1.4 (n = 330). There
Between-group differences were examined with Kruskal- were no significant differences among the respective
Wallis tests, using the Mann-Whitney U tests for post- groups (p = 0.803), specialities (p = 0.578), genders (p =
hoc two-group comparisons. Two-sided p < 0.05 were 0.294) or other demographic data.
considered statistically significant. Due to the explora- Physicians estimated the prevalence of active trigger
tory nature of our analyses, no alpha adjustments for points to 46.1 ± 27.4% (n = 329) in the overall popula-
multiple testing were undertaken. tion and 52.8% ± 26.9 (n = 330) in their own patients.
Subjects from the pain congress rated these frequencies
Results higher than other physicians; 55.4 ± 22.2% in the overall
Demographic and participants characteristics population (p < 0.001) and 63.4 ± 21.7% in their own
Three hundred thirty-two physicians with a mean age of patients (p = 0.001). For detailed information see Table
47.5 ± 9.6 years (85 female, 25.6%, 43.6 ± 9.2 years; 235 S2 (additional file 3).
male, 70.8%, 48.8 ± 9.4 years) responded to the ques-
tionnaire. Among all physicians, 146 (44.0%) were ortho- Prescription Rates of treatment options
paedists, 97 (29.2%) internists and 63 (19.0%) Analgesics
anaesthetists. Out of these groups, 90 (27.1%) were sub- Pharmacological approaches were the most common
specialised in rheumatology and 50 (15.1%) in pain ther- treatment (1525 choices, i.e. a mean of 4.5 analgesics
apy. Thirty-seven (11.1%) doctors worked at a university evaluated per physician). Non steroidal anti-inflamma-
hospital, 113 (34.0%) at a county hospital, 160 (48.2%) tory drugs or coxibs were the main analgesics (n = 304,
in a private clinic, 2 (0.6%) in a pain centre and 20 91.6%), followed by metamizol and paracetamol (n =
(6.0%) did not specify their place of work. Forty-one 289, 87.0%), weak opioids (n = 271, 81.6%), antidepres-
(12.3%) physicians were residents and 281 (84.6%) con- sants (n = 240, 72.3%), strong opioids (n = 190, 57.2%)
sultants. The detailed affiliations and professional status or anticonvulsants (n = 175, 52.7%). Other drugs were
of the respondents are shown in Table S1 (additional rarely used (n = 56, 16.9%), physicians named especially
file 2). muscle relaxants (n = 17, 5.1%) and flupirtine (n = 16,
Congress groups showed differences regarding age, 4.8%). Detailed intra- and inter-group values are shown
gender and the work centre. Female rheumatologists in Figure 1 and Table S3 (additional file 4).
were younger than male rheumatologists. In general, Physical therapy
women were not only younger but also differently dis- Physical therapies were prescribed one-third less often
tributed within the groups of specialisation and subspe- than analgesics (1118 choices, i.e. a mean of 3.4 physical
cialisation when compared to men. There were less therapies evaluated per physician). Manual therapy was
female surgeons than female rheumatologists or anaes- prescribed most often, i.e. by 270 (81.1%) of all physi-
thetists. Physicians working in a hospital were younger cians, followed by TENS (n = 242, 72.9%) and acupunc-
than those in a private clinic. ture (n = 200; 60.2%). Ultrasound (n = 132, 39.8%),
When asked for the number of myofascial pain percussion waves (n = 106, 31.9%) or dry needling (n =
patients treated, 163 (48.9%) of all physicians attended 96, 28.9%) were prescribed less often. Additional treat-
more then four patients a week, 87 (26.1%) between one ments were chosen by 72 (21.7%) of all physicians.
and three patients a week, 39 (11.7%) between one and These treatments were rather specified e.g. chiropractics
three patients per month, 36 (10.8%) up to ten patients (n = 8), cryotherapy (n = 3) and osteopathy (n = 3) as
a year and 6 (1.8%) physicians never saw myofascial other physical therapy. Detailed intra- and inter-group
pain patients. There were no intergroup differences values are shown in Figure 1 and Table S3 (additional
regarding those distributions (p = 0.801). file 4).
When we asked how often patients were referred to Injections
special pain centres, we found the following distribution: The use of injection techniques is less important in the
82 (24.6%) of physicians never did, 89 (26.7%) up to ten overall therapeutic concept (390 choices, i.e. a mean of
patients per year, 96 (28.8%) up to three patients per 1.2 injections evaluated per physician). Injection of local
month, 25 (7.5%) between one and three patients a anaesthetics was mainly used (n = 236; 71.1%). Spinal
week and 26 (7.8%) referred more than four patients a interventions (e.g. spinal cord stimulation, epidural
week to a specialised pain centre. Pain therapists rarely injection) was used by 102 (30.7%) whereas injection of
refer their patients to another centre (p < 0.001). For botulinum toxin was used by 41 (12.3%) of physicians.
detailed information see Table S1 (additional file 2). Additional techniques (n = 11, 3.3%) were not specified.
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Analgesics
NSAIDs' and coxibes Mean
Metamizol and paracetamol
Weak opioids
pain therapists
Antidepressants orthopaedists
Strong opioids rheumatologists
Anticonvulsants
Others
Muscle Relaxants
Flupirtine

Physical therapies
Manual Therapy
TENS
Acupuncture
Ultrasound
Percussion waves
Dry needling
Others

Injections
Injection of local anaesthetics
Spinal interventions
Injection of botulinum toxin
Others

0 20 40 60 80 100
Prescription Rate (in %)

Figure 1 Prescription Rate. demonstrates the physician estimated prescription rate of different therapeutic options in the treatment of
myofascial pain. Circles indicate the overall average; the prescription rates of three subgroups (Pain therapists, rheumatologists and
orthopaedists) are shown by triangles or squares (please refer to legend). Data are expressed in percent (%). TENS: transcutaneous electrical
stimulation.

Detailed intra- and inter-group values are shown in Fig- strong opioids were rated less effective by pain therapists
ure 1 and Table S3 (additional file 4). than orthopaedists (p < 0.001) or rheumatologists (p <
0.01); pain therapists rated anticonvulsants worse than
Rating of treatment approaches orthopaedists (p = 0.008); Other pharmacologic treatments
A 6-point scale (with 1 being excellent effective and 6 scored better in the pain group then with orthopaedists
being worst) allowed physicians to rate the effectiveness (p = 0.007) or rheumatologists (p = 0.018).
of the used treatment approaches. 54.3% of all physi- Physical therapies
cians surveyed stated current symptom-based treatment Manual therapy was rated with an average of 2.3 ± 0.9.
options being insufficient. This opinion was more pro- Dry needling (2.4 ± 1.1) and acupuncture (2.4 ± 1.0)
nounced in the rheumatologists group (77.3%) than were estimated with a similar effectiveness. TENS (2.6 ±
anaesthetists (49.2%) or orthopaedists (45.8%). 0.9) scored better than percussion waves (2.8 ± 1.2).
Analgesics Ultrasound techniques were estimated being the less
Muscle relaxants (2.1 ± 0.5) and flupirtine (1.6 ± 0.7) are effective therapeutic option (3.0 ± 1.2). Additional treat-
estimated as most effective analgesics. They form part of ments (e.g. chiropractics, osteopathy) were rated 2.0 ±
additional assignable drugs (overall 2.3 ± 1.1 points). They 0.9. Detailed intra- and intergroup data are shown in
were followed by antidepressants (2.6 ± 1.0), non-steroidal Figure 2 and Table S4 (additional file 5).
anti-inflammatory drugs or coxibs (2.7 ± 1.0), metamizol There were intragroup differences regarding the rating
or paracetamol (3.1 ± 1.0), weak opioids (3.1 ± 1.1), strong of TENS (p = 0.001), manual therapy (p = 0.002) and acu-
opioids (3.2 ± 1.5) and anticonvulsants (3.2 ± 1.2). Detailed puncture (p = 0.006). TENS got a better ranking by ortho-
intra- and intergroup data are shown in Figure 2 and paedists (p = 0.001) and pain therapists (p < 0.001) when
Table S4 (additional file 5). compared to rheumatologists. The same held for manual
There were significant intragroup differences regarding therapy (p = 0.001, p = 0.1) and acupuncture (p = 0.008, p
the rating of treatment options for non-steroidal anti- = 0.002). Ultrasound was rated better by orthopaedists
inflammatory drugs or coxibs (p = 0.002), weak and strong than pain therapists (p = 0.033); Dry needling was rated
opioids (p < 0.001), anticonvulsants (p = 0.024) and addi- better by pain therapists than orthopaedists (p = 0.039) or
tional pharmacologic approaches (p = 0.006). Non-steroi- rheumatologists (p = 0.044).
dal anti-inflammatory drugs or coxibs were rated better Injections
by orthopaedists when compared to pain therapists Injection of local anaesthetics was rated with an average
(p = 0.018) or to rheumatologists (p = 0.001); weak and of 2.3 ± 1.0 and injection of botulinum toxin scored
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Analgesics
NSAIDs' and coxibes mean
Metamizol and paracetamol pain therapists
Weak opioids orthopaedists
Antidepressants rheumatologists
Strong opioids
Anticonvulsants
Other s
Muscle Relaxants
Flupirtin e

uneffectiv e

excellent
Physical therapies
Manual therapy
TENS
Acupuncture
Ultrasound
Percussion waves
Dry needling
Others

Injections
Injection of local anaesthetics
Spinal interventions
Injection of botulinum toxin
Others

6.0 4.0 3.5 3.0 2.5 2.0 1.5 1.0

Effectiveness Rating Score (range 1-6)

Figure 2 Ratings of Treatment Options. demonstrates the physician estimated efficacy of different therapeutic options in the treatment of
myofascial pain on a 6-fold scale (with 1 being “excellently effective” and 6 being “ineffective”). Ratings towards the lower ranks on the value
axis indicate a higher estimated effectiveness. Data are expressed as mean ± SD. (*), (**) and (***) express the different levels of significance p <
0.05, 0.01 and 0.001. Between-group differences were examined with Kruskal-Wallis tests, using the Mann-Whitney U tests for post-hoc two-
group comparisons. Stars are placed upon the confirmed group, respectively. TENS: transcutaneous electrical stimulation.

2.8 ± 1.4. Spinal interventions scored worst (2.9 ± 1.8). Discussion

Additional but unspecified injections scored 1.9 ± 0.5. To our knowledge, the present study is the first physi-
Detailed intra- and intergroup data are shown in Figure cians survey that estimates the prevalence and clinical
2 and Table S4 (additional file 5). importance of myofascial pain and the utilization rate
There were intragroup differences regarding the rating and physician rated effectiveness of the most common
of injection of local anaesthetics (p = 0.008). This con- treatment options. Our data suggests that German phy-
cerned the rheumatologists group when compared to sicians that treat various pain issues considered myofas-
pain therapists (p = 0.032) or orthopaedists (p = 0.002). cial pain a highly prevalent condition. Though,
Injections were rated differently by orthopaedists and prescription rate and estimated effectiveness of pre-
rheumatologists (p = 0.021). scribed treatments showed significant discrepancies: the
Correlations between participant characteristics and most frequently prescribed treatments were not rated
treatment approaches the most effective (Figures 1, 2). In addition, our data
A gender effect could be demonstrated for the use of revealed significant discrepancies regarding the treat-
spinal interventions (p = 0.049), which is rarely used by ment of myofascial pain in different fields of
women, while they prefer manual therapy (p = 0.019). specialisation.
Physicians younger than 35 years rated the use of
weak (p = 0.002) and strong opioids (p = 0.009) less Implications for treatment options
effective than those older than 65 years. This current survey demonstrates that physicians esti-
Working place-related effects appeared different: phy- mated the effectiveness of frequently prescribed analge-
sicians employed at district hospitals (n = 113) esti- sics as unsatisfactory. For example commonly used
mated non-steroidal anti-inflammatory drugs or coxibs analgesics such as NSAID and coxibs, metamizol and
more effective than physicians working in a private paracetamol and weak opioids were estimated moder-
practice (n = 160, p = 0.018). ately in their effectiveness. This lack of concordance
Comparing the ratings of residents and consultants, between frequently prescribed treatments and perceived
it became evident that residents evaluated weak effectiveness reflects the lack of scientific evidence and
(p = 0.004) and strong opioids (p = 0.001), antidepres- available treatment guidelines. Consensus is also requi-
sants (p = 0.049) and dry needling (p = 0.042) less site among researchers to define and describe myofascial
effective. pain using standard terminology and validated
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examination techniques [15]. In part, our observations diagnosis and treatment of myofascial pain. Bishop et al.
could relate to the confusion and controversy among could recently demonstrate diversity of the attitudes of
physicians regarding the treatment of myofascial pain general practitioners and physiotherapists in the United
disorders. At least, according to our survey, physicians Kingdom (UK) towards low back pain patients. Against
seem to be aware of the ambiguity of their treatment the line of clinical guidelines a quarter of respondents
approaches effectiveness. However Wheeler reports that believed in avoidance of physical activity or the need to
most experts recommend medication as an adjunctive be off work as part of treatment regimen [25]. This sug-
treatment to injection and exercise therapy in acute and gests that the lack of availability of recommendations or
chronic musculoskeletal pain. expert opinions to health professionals is a widespread
Similar observations have been made by Tsang and phenomenon. As a corollary, those wishing to accelerate
her colleagues in the treatment of chronic vascular dis- the adoption of new evidence may need to undertake
ease. A knowledge gap caused by lack of awareness of more active promotion [26], in order to obtain generally
the evidence or familiarity with current treatments leads accepted guidelines [27].
to a so called evidence-to-practice care gap [24].
We observed that the perceived effectiveness of some Implications for clinical practice and for future research
treatments that require specialized education and addi- It remains interesting why physicians estimated seldom
tional experience, including acupuncture, TENS, dry used pharmacologic remedies as very effective, e.g. mus-
needling or injections varied among specialist. In gen- cle relaxants, chiropractics or flupirtine. Flupirtine for
eral, these techniques were rated to be controversial; example appeared as a scientifically promising but not
especially by physicians not familiar with these practical yet prevalent treatment option [28]. Large clinical trials
treatments. For example, ratings for injection techniques for the use of flupirtine in the treatment of myofascial
(e.g. spinal interventions) differed in between groups, pain are lacking. Yet, prescription patterns and per-
what could be explained by a particular enhanced use of ceived effectiveness of these rarely used treatments in
invasive methods in the respective clinical fields. The the view of treating physicians have still to be evaluated.
choice of treatment might depend on the professional To conclude, a facilitated access to the latest outcome
career of the physicians. For example orthopaedists, by in pain research might be desirable to get an overview
specialisation familiar with surgical techniques, were of potential treatment options.
estimating injections better. In contrast, rheumatologists, The majority of physicians, even whilst prescribing,
familiar with pharmacologic treatments, estimated phar- characterized the available symptomatic treatment
macologic approaches better. There were also differ- options as insufficient. This might also reflect the chal-
ences regarding the rating of group related treatments lenge to understand the sophisticated pathogenic path-
such as ultrasound and percussion waves that could be ways that may lead to myofascial pain syndromes. The
due to different educational access. Taken together complexity of pathogenesis might also be expressed
these data suggest that the estimated efficacy of treat- regarding the multitude of different available treatment
ment options for myofascial pain syndrome is mostly approaches. This survey did e.g. not approach the psy-
influenced by the speciality-related training and educa- chosocial aspects of treatments event though it is sup-
tion of the physicians. posed that the occurrence of depression has been
In addition our data show that other physician-related related to pain syndromes of the joints and musculoske-
parameters may influence the choice of treatment. We letal system [29]. It is commonly understood that
analysed the impact of working place or status of specia- chronic myofascial pain may be a consequence of
lisation. While physicians in the pain congress group a complex stress response that extends beyond the
mainly worked in hospitals, those members that had nervous system and contributes to the experience of
chosen a private practice as their working place rated pain [30].
treatments differently, which might reflect the differ- In addition, physicians estimated the prevalence of active
ences in work experience in these groups. It might also trigger points. Almost every second person is considered
influence the choice and rating of treatments. We could having active trigger points, thus supporting physicians
also demonstrate that use and evaluation of treatments opinion considering myofascial pain a highly prevalent
are influenced by the status of specialisation. It might condition. Myofascial trigger points have been described
also be possible that previously learned strategies are as a ‘common cause of pain in clinical practice’ and an
kept out of mind. It has been shown that physicians ‘extremely common, yet commonly overlooked’ source of
reconsider the use of evidence-based treatments by sim- musculoskeletal disorders [31]. The evidence of Simon
ple patient-specific prompting [24]. and Travells statement, as well as our results based on
Access to education in the treatment of myofascial physicians opinions and experience, is limited as there is
pain seems to be an important fact whilst improving no available diagnostic gold standard for mTrPs based on
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a laboratory test or imaging technique [3]. Diagnosis is prescribing practices is to analyse the actual process in
confirmed by clinical history and physical examination, detail. But even then, this approach would not provide
free from systemic inflammatory, autoimmune or other an understanding of the perceived effectiveness of the
locomotor system disease. prescribed treatments.
Clinically, an active (symptom-producing) central Our questionnaire regarded the myofascial pain syn-
myofascial trigger point can be defined as a hyperirrita- drome as a single entity. One reason was the current
ble nodule of spot tenderness in a palpable taut band of lack of strict classification criteria for distinct clinical
skeletal muscle. The spot is a site of exquisite tender- entities. The participants of this study might handle dif-
ness to palpation from which a local twitch response ferent aspects of the myofascial pain syndrome and
can be elicited when appropriately stimulated, that refers therefore choose different treatments. We took the
pain to a distance, and that can cause distant motor and approach on introducing questions on myofascial trigger
autonomic effects. points at the beginning of the questionnaire to help
These clinically findings have not been proven to be ensure that the physicians responses related to the treat-
reliable, as stated in a recent review by Lucas et al. [32]. ment of myofascial pain syndrome rather than other
However there is no validated list of diagnostic criteria soft tissue pain conditions such as fibromyalgia.
for mTrPs. Two pilot studies with a small number of The questionnaire has not undergone formal valida-
subjects evaluating various diagnostic tests [33,34] tion. The objective of this study was to analyse and pro-
reported good overall interrater reliability. They vide an overview of the diversified customs of German
reported examining for a taut band, spot tenderness, a physicians in the treatment of myofascial pain syn-
palpable nodule, elicited referred pain, and the local drome. Given the purpose of the questionnaire, valida-
twitch response [3]. Licht et al. recently demonstrated tion is not necessary.
that some ‘key’ diagnostic criteria acc. to Simons and
Travell [31] of myofascial trigger points could reliably Conclusions
be found by two different examiners in a smaller sample The results of this survey demonstrate that there is no
group [35]. Harden et al. presented 2000 a list of addi- agreement amongst German specialist in the utilization
tional 31 signs and symptoms that are related to myo- and perceived effectiveness of the various common
fascial disorders [36]. treatment options for myofascial pain. In view the low
Our data demonstrate that active myofascial trigger rating of effectiveness, physicians seem to be aware of
points are considered prevalent and related to myofas- this drawback. We believe that guidelines for the treat-
cial pain by the physicians. Hence, the lack of concor- ment of myofascial pain syndrome are necessary.
dance in this field is limiting the conclusion how far this Neither standard diagnostic procedures to identify myo-
observation may contribute to the thesis that trigger fascial pain nor discriminating variables to distinguish
point diagnosis is reliable. the different entities of myofascial pain syndrome are
available. Therefore we conclude that multiple diagnos-
Methodological considerations tic approaches may lead to therapeutic confusion.
It is commonly understood that chronic myofascial pain All things considered, beside education in the manage-
may be a consequence of a complex stress response that ment of myofascial pain syndrome and enhancing man-
extends beyond the nervous system and contributes to ual skills, clinical investigation is necessary to develop
the experience of pain. standard guidelines in the diagnosis and treatment of
As we chose personal contact instead of postal distri- myofascial pain syndrome.
bution almost everyone asked responded to the ques-
tionnaire (response-rate > 95%). Additional file 1: Questionnaire on myofascial pain. Please find
In any attempt to examine the clinical practice of detailed description of the questionnaire within the manuscript.
Click here for file
myofascial pain syndrome management for an entire [ http://www.biomedcentral.com/content/supplementary/1471-2474-11-
population of physicians in a country, a questionnaire 32-S1.DOC ]
study is the most feasible method. However, we do not Additional file 2: Table S1 - Demographic and participants
know to what extent the physicians’ responses represent characteristics (mean ± SD or in %). Table S1 provides the
demographic data of physicians dealing with myofascial pain: age,
their actual practice, or whether is their perception of gender, field of specialisation, subspecialisation, employment centre and
professional behaviour. It remains an open question status of specialisation. We asked for the physician’s average number of
whether the physicians’ skills and abilities to treat myo- treated myofascial pain patients (Treatment ratio) and the number of
patients referred to specialised pain centres (Referral Ratio). Data are
fascial pain syndrome are reflected in the answers and expressed as mean ± SD or as total count (n) and in percent (%).
ratings to the questions. It is our belief that the ques- Click here for file
tionnaire addresses central elements in myofascial pain [ http://www.biomedcentral.com/content/supplementary/1471-2474-11-
32-S2.DOC ]
management. The only reliable way to measure
Fleckenstein et al. BMC Musculoskeletal Disorders 2010, 11:32 Page 8 of 9
http://www.biomedcentral.com/1471-2474/11/32

randomized controlled trial [ISRCTN75722066]. BMC Musculoskelet Disord

Additional file 3: Table S2 - Estimated prevalence (mean ± SD). 2007, 8:107.
Table S2 provides the physician estimated importance of myofascial pain 10. Irnich D: Trigger Point Manual [Leitfaden Triggerpunkte] Munich, Jena:
in the general population on a six-point scale (with 1 being a “very Elsevier, Urban&Fischer 2008.
common problem”). Additionally the physician estimated prevalence of 11. Lavelle ED, Lavelle W, Smith HS: Myofascial trigger points. Anesthesiol Clin
active trigger points in the general population and their respective 2007, 25:841-851, vii-iii.
patients in percent (%) is given. Data are expressed as mean ± SD. 12. Srbely JZ: Ultrasound in the management of osteoarthritis: part I: a
Click here for file review of the current literature. JCCA J Can Chiropr Assoc 2008, 52:30-37.
[ http://www.biomedcentral.com/content/supplementary/1471-2474-11- 13. Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J, Krauss M, Natalis M,
32-S3.DOC ] Senn E, Beyer A, Schops P: Randomised trial of acupuncture compared
Additional file 4: Table S3 - Prescription Rate of Treatment Options with conventional massage and “sham” laser acupuncture for treatment
(in %). Table S3 indicates the physician estimated prescription rate of of chronic neck pain. Bmj 2001, 322:1574-1578.
different therapeutic options in the treatment of myofascial pain. Data 14. Castien RF, Windt van der DA, Dekker J, Mutsaers B, Grooten A:
are expressed in percent (%). TENS: transcutaneous electrical stimulation. Effectiveness of manual therapy compared to usual care by the general
Click here for file practitioner for chronic tension-type headache: design of a randomised
[ http://www.biomedcentral.com/content/supplementary/1471-2474-11- clinical trial. BMC Musculoskelet Disord 2009, 10:21.
32-S4.DOC ] 15. Wheeler AH: Myofascial pain disorders: theory to therapy. Drugs 2004,
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(mean ± SD). Table S4 indicates the physician estimated efficacy of 16. Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW: Back
different therapeutic options in the treatment of myofascial pain on a 6- schools for nonspecific low back pain: a systematic review within the
fold scale (with 1 being “excellently effective” and 6 being “ineffective”). framework of the Cochrane Collaboration Back Review Group. Spine
Data are expressed as mean ± SD. TENS: transcutaneous electrical 2005, 30:2153-2163.
stimulation. 17. Ga H, Choi JH, Park CH, Yoon HJ: Acupuncture needling versus lidocaine
Click here for file injection of trigger points in myofascial pain syndrome in elderly
[ http://www.biomedcentral.com/content/supplementary/1471-2474-11- patients–a randomised trial. Acupunct Med 2007, 25:130-136.
32-S5.DOC ] 18. Cummings M, Baldry P: Regional myofascial pain: diagnosis and
management. Best Pract Res Clin Rheumatol 2007, 21:367-387.
19. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW,
Berman BM: Acupuncture and dry-needling for low back pain. Cochrane
Database Syst Rev 2005, CD001351.
Acknowledgements 20. Tough EA, White AR, Cummings TM, Richards SH, Campbell JL:
We want to thank Dr. Alexander Crispin, Department of Biometry, Acupuncture and dry needling in the management of myofascial trigger
Epidemiology and Medical Informatics, University of Munich, Germany, for point pain: a systematic review and meta-analysis of randomised
his support whilst performing the statistical analysis. controlled trials. Eur J Pain 2009, 13:3-10.
21. Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S: Medicinal and
Authors’ contributions injection therapies for mechanical neck disorders. Cochrane Database Syst
JF conceived the study, performed the statistical analysis and drafted the Rev 2007, CD000319.
manuscript. DZ, LL and FF recruited and assessed participants. LJR and PML 22. Ho KY, Tan KH: Botulinum toxin A for myofascial trigger point injection: a
participated in the design of the study and helped drafting the manuscript. qualitative systematic review. Eur J Pain 2007, 11:519-527.
DI participated in the design and coordination of the study and supervised 23. Cummings TM, White AR: Needling therapies in the management of
drafting the manuscript. All authors read, and approved of, the final myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil
manuscript. 2001, 82:986-992.
24. Tsang JL, Mendelsohn A, Tan MK, Hackam DG, Leiter LA, Fitchett D, Lin PJ,
Competing interests Grima E, Langer A, Goodman SG: Discordance between physicians’
The authors declare that they have no competing interests. estimation of patient cardiovascular risk and use of evidence-based
medical therapy. Am J Cardiol 2008, 102:1142-1145.
Received: 12 May 2009 25. Bishop A, Foster NE, Thomas E, Hay EM: How does the self-reported
Accepted: 11 February 2010 Published: 11 February 2010 clinical management of patients with low back pain relate to the
attitudes and beliefs of health care practitioners? A survey of UK general
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Pre-publication history
The pre-publication history for this paper can be accessed here:http://www.
biomedcentral.com/1471-2474/11/32/prepub

doi:10.1186/1471-2474-11-32
Cite this article as: Fleckenstein et al.: Discrepancy between prevalence
and perceived effectiveness of treatment methods in myofascial pain
syndrome: Results of a cross-sectional, nationwide survey. BMC
Musculoskeletal Disorders 2010 11:32.

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