Pain Medicine, 0(0), 2020, 1–11

doi: 10.1093/pm/pnaa253
Review Article

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Effect of Physical Exercise Programs on Myofascial Trigger Points–
Related Dysfunctions: A Systematic Review and Meta-analysis
 Guzma
Marıa Jose n-Pavo n Cavero-Redondo, PhD,†,‡ Vicente Martınez-Vizcaıno, PhD, MD,†,§
 n, MSc* Iva
Ruben Ferna 
ndez-Rodrıguez, MSc,† Sara Reina-Gutierrez, MSc,† and Celia Alvarez-Bueno, PhD †,‡

*Universidad de Castilla-La Mancha, Faculty of Physiotherapy and Nursing, Toledo, Spain; †Universidad de Castilla la-Mancha, Health and Social
Research Center, Cuenca, Spain; ‡Universidad Polit on, Paraguay; §Universidad Aut
ecnica y Artıstica del Paraguay, Asunci onoma de Chile, Facultad de
Ciencias de la Salud, Talca, Chile

Correspondence to: Ivan Cavero-Redondo, PhD, Universidad de Castilla la-Mancha, Health and Social Research Center, Santa Teresa Jornet,
s/n, 16071 Cuenca, Spain. Tel: þ34-969179100; Fax: þ34-969179100; E-mail: [email protected].

Funding sources: This study was funded by FEDER funds.

Conflicts of interest: No conflicts of interest were reported for this study.

Abstract
Objective. Myofascial pain syndrome is one of the primary causes of health care visits. In recent years, physical exer-
cise programs have been developed for the treatment of myofascial trigger points, but their effect on different out-
comes has not been clarified. Thus, this study aimed to assess the effect of physical exercise programs on myofas-
cial trigger points. Methods. A systematic search was conducted in Pubmed, Web of Science, and Scopus. Articles
analyzing the effect of physical exercise programs on pain intensity, pressure pain threshold, range of motion, and
disability were included. Risk of bias was assessed using the Cochrane RoB2 tool. The DerSimonian-Laird method
was used to compute the pooled effect sizes (ES) and their 95% confidence interval (95% CI) for pain intensity, pres-
sure pain threshold, range of motion, and disability. Results. A total of 24 randomized controlled trials were included
in this systematic review and meta-analysis. The pooled ES were –0.47 (95% CI ¼ –0.61 to –0.33) for pain intensity,
0.63 (95% CI ¼ 0.31 to 0.95) for pressure pain threshold, 0.43 (95% CI ¼ 0.24 to 0.62) for range of motion, and –0.18
(95% CI ¼ –0.45 to 0.10) for disability. Conclusions. Physical exercise programs may be an effective approach in the
treatment of pain intensity, pressure pain threshold, and range of motion among patients with myofascial trigger
points.

Key words: Systematic Review; Myofascial Trigger Points; Exercise; Physical Activity

Introduction the taut bands of skeletal muscles that become painful

when stimulated (e.g., compression or other mechanical
Myofascial pain syndrome (MPS) is one of the most im-
stimulations) and that can induce a typical pattern of re-
portant causes of musculoskeletal pain [1] and one of the
ferred pain, motor dysfunction, and autonomic responses
most common causes of health care visits, absenteeism,
[7]. Other characteristic effects are increased tension, mus-
and disability [2]. MPS has a lifetime prevalence of up to
cle shortening, restricted range of motion, impaired muscle
85% in the general population [2] and is the primary di-
activation pattern, weakness, and increased muscle fatigue
agnosis for 85% of patients with chronic pain seen in
[7–10]. Clinically, MTPs are classified as active or latent.
pain care centers [3]. Also, MPS prevalence is consider-
Both present similar physical findings, except that latent do
ably high among specific pathologies, such as patellofe-
no elicit spontaneous symptoms and the referred pain is not
moral pain [4], lateral epicondylalgia [5], or chronic
recognized as familiar to the patient [7].
tension-type headache [6]. The most effective methods to manage MPS are aimed
The origin of MPS is located at the myofascial trigger to treat MTPs, as MTPs are the main cause of generalized
points (MTPs), which are hyperirritable regions placed in

C The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.
V
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and referred pain in myofascial pain disorders [11]. However, evidence of the effectiveness of these PE
Different techniques have been proposed for MTPs treat- treatment strategies for MTPs is scarce and inconsistent.
ment. Evidence suggests that interventions such as dry Therefore, the objective of this systematic review and
needling [12], light amplification by stimulated radiation meta-analysis was to assess the effect of PE interventions

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emission (LASER) [13], and manual therapy [14] are ef- on MTP dysfunctions, including pain intensity, pressure
fective in treating MTPs, while evidence of the effective- pain threshold, range of motion, and disability.
ness of interventions such as myofascial release [15],
ultrasound (US) [16], transcutaneous electrical nerve
stimulation (TENS) [17], shock wave [18], and a combi- Methods
nation of stretch and strengthening exercises [19] is not Data Sources and Search Strategy
as consistent. This systematic review and meta-analysis followed the
Additionally, participating in physical exercise (PE) Cochrane Handbook [37] and is reported using the
programs for the treatment of pathologies closely related PRISMA statement [38]. The protocol for this systematic
to MTPs, such as osteoarthritis, osteoporosis, rheuma- review was previously registered in PROSPERO with the
toid arthritis, chronic low-back pain, cervical pain, ID number CRD42020152988.
or shoulder pain, has been increasingly recommended To identify all studies reporting the effects of PE pro-
[20–22]. More recently, exercise-based interventions grams on pain intensity, pressure pain threshold, range of
have been proposed due to their noninvasive, nonphar- motion, and disability in patients with MTPs, a system-
macological, low-cost, and safety features. In addition to atic search of the electronic databases PubMed, Scopus,
their adaptability to patients’ characteristics and positive and Web of Science (WoS) from the inception of the
association to pathologies, PE interventions have benefits databases to February 2020 was conducted. The search
on physical and mental functions, such as quality of life, strategy included the following terms: “trigger points,”
sleep, anxiety, and depression [23]. Physical exercise pro- “myofascial pain,” “myofascial pain syndrome,” “dry
grams may be an interesting add-on therapy during treat- needling,” “exercise,” “exercise therapy,” “physical
ment and in combination with other techniques, such as activity,” “trigger point therapy,” “physical therapy,”
dry needling, which has been shown to be useful in the “acupuncture,” and “physiotherapy.” The complete
treatment of MTPs (level of evidence 1A) [12] or with search strategy for MEDLINE is presented in the
other interventions, when dry needling is contraindicated
Supplementary Data. Additionally, the references of the
or the patient refuses this treatment. Moreover, exercise-
included studies were reviewed for any relevant studies.
based interventions are necessary to manage the conse-
quences of MTPs such as impaired muscle activation pat-
Study Selection
terns [8], weakness [9], and increased fatigability [10]
Two reviewers (MJG-P and CA-B) independently
and, therefore, to promote a better response to treatment
searched the databases. Disagreements were solved by
and to restore the optimal state of the muscles.
consensus or discussion with a third reviewer (VM-V).
Several types of PE may be prescribed for the treat-
ment of MTPs, including stretching [24], aerobic and
strength exercises [25], and some types of combined exer-
Inclusion Criteria
cises [26]. Several mechanisms have been proposed to ex- The criteria for the inclusion of studies were as follows:
plain the positive effects of PE on MTPs: 1) Aerobic and 1) design: randomized controlled clinical trials (RCTs);
isometric exercise may induce hypoalgesia and increase 2) participants with MTPs; 3) type of intervention: any
pressure pain threshold by reducing central sensitivity, type of PE intervention; 4) comparison: control or a non-
resulting in multisegmental pain-inhibitory effects. PE intervention group; and 5) outcomes: pain intensity,
Additionally, exercise-induced hypoalgesia (EIH) has pressure pain threshold, range of motion, and disability.
been found to be larger in the exercising body part com- Studies were excluded when 1) the study of MTPs was
pared with remote sites, which indicates that local or seg- not the main objective; 2) the PE program was based on
mental mechanisms could play an important role in EIH stretching exercises; and 3) studies were not written in
[27–30]. 2) Muscular contraction could favor the drain- English, Spanish, French, or Italian.
age of sensitizing substances, which are presented in the
MTP environment, and therefore reduce the central and Data Extraction
peripheral sensitizations that cause local and/or referred To examine the effect of the PE programs on MTPs out-
pain [31]. Moreover, aerobic exercise triggers the release comes, two reviewers (MJG-P and CA-B) independently
of anti-inflammatory cytokines, insulin-like growth fac- extracted the following data from each included article:
tor–1 (IGF-1) and its binding protein (IGFBP-3), which i) author and date of publication; ii) musculoskeletal
are involved in the neuroinflammatory response [32–34]. region evaluated, sample size by group, and mean age;
3) Finally, muscle contraction could cause localized iii) intervention, dose, and length of the intervention; and
stretching of MTPs and, therefore, normalization of the iv) outcomes measured. Disagreements in data collection
sarcomeres [35, 36]. were settled by consensus.
Effect of Exercise on Myofascial Pain 3

Risk of Bias Assessment The musculoskeletal regions most frequently evalu-

Two researchers (MJG-P and CA-B) independently ated were the cervical [26, 44–52], facial [42, 43, 53–58],
assessed the risk of bias of the RCTs included by applying and shoulder areas [25, 26, 45, 46, 51, 52, 59, 60]. Other
the Cochrane Collaboration’s tool for assessing risk of regions evaluated were the scapular [47, 61], lower back

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bias (RoB2) [39]. Any disagreement was resolved by con- [52, 62], upper back [48], hip [41], thorax [52], and sev-
sensus or by discussion with a third reviewer (VM-V). eral regions of the upper limbs [52].
This tool assesses the risk of bias according to five The studies included strength, aerobic, coordination, pro-
domains: bias derived from the randomization process, prioception, and postural correction exercises. The frequency
bias due to deviations from planned interventions, bias of PE programs ranged from one to five times per week,
due to lack of results data, bias in the measurement of with a total duration ranging between one and 24 weeks.
the result, and bias in the notification of the results. Each The sessions lasted from 10 to 60 minutes per day.
domain could score as low, moderate, or high risk of According to MTP outcomes, 21 studies [26, 42–46,
bias. Finally, an overall risk of bias score was provided. 48–62] assessed pain intensity, 15 [25,26,42,43,45,47–
49,54,55,58–62] pressure pain threshold, nine [41, 43,
Data Synthesis and Analysis 49, 50, 53, 55, 58–60] range of motion, and six [42, 45,
The pooled effect size (ES) estimates and their 95% con- 46, 50, 59, 60] disability. Other parameters reported
fidence intervals (95% CI), using the DerSimonian-Laird were muscular tension [46, 61], functionality [59, 60],
random-effects model [40], were calculated for each out- quality of life [45, 51], depression [51, 62], anxiety [61],
come (i.e., pain intensity, pressure pain threshold, range fatigue, psychological status, emotional distress, and
of motion, and disability) using pre–post values. The clin- sleep quality [53], posture [56], and kinesiophobia [62].
ical significance of the pooled ES was interpreted accord-
ing to Cohen’s statements, suggesting that d ¼ 0.2 be Risk of Bias Assessment
considered a “small” ES, 0.5 a “medium” ES, and 0.8 a One study was assessed as low risk of bias, 15 as some
“large” ES. Pooled ES were estimated with negative val- concerns, and eight as high risk of bias. Regarding each
ues for pain intensity and disability and positive values domain specifically, the quality of studies was rated as
for pressure pain threshold and range of motion, both low risk for each domain as follows: 58.3% in the ran-
meaning an effect in favor of the PE intervention. domization process, 16.6% in the blinding of partici-
Heterogeneity was assessed using the I2 statistic, and the pants and researchers, 37.5% in the measurement of the
following values were used for interpretation: not impor- results, and 95.8% due to selection of the reported results
tant (0–40%), moderate (30–60%), substantial (50– and missing outcome data (Supplementary Data).
90%), and considerable (75–100%). Corresponding P
values were also considered [39]. Efficacy of PE on Pain Intensity, Pressure Pain
Sensitivity analyses were performed excluding studies Threshold, Range of Motion, and Disability
one by one from the pooled estimates in order to evaluate The pooled ES estimates (Figures 1–4) for the effect of PE
whether any particular study modified the original sum- programs were i) –0.47 (95% CI ¼ –0.61 to –0.33) for
mary estimate. Finally, publication bias was estimated pain intensity; ii) 0.63 (95% CI ¼ 0.31 to 0.95) for pres-
using Egger’s test. sure pain threshold; iii) 0.43 (95% CI ¼ 0.24 to 0.62) for
All statistical analyses were conducted using Stata 15 range of motion; and iv) –0.18 (95% CI ¼ –0.45 to 0.10)
software. for disability. Heterogeneity was moderate for pain in-
tensity (I2 ¼ 30.1%) and substantial for pressure pain
threshold (I2 ¼ 80.1%). There was no presence of hetero-
Results
geneity for range of motion and disability.The sensitivity
Study Selection analyses showed that results were not substantially modi-
The initial search retrieved 5,906 studies, and after exclu- fied when each study was removed from the analyses one
sion of nonrelevant studies, 42 studies were assessed for at a time for any MTPs outcome (Supplementary Data).
eligibility. Of these, 24 RCTs met the inclusion criteria Finally, no publication bias was found as assessed by
and were included in this systematic review and meta- Egger’s test or observed in funnel plot asymmetry
analysis (Supplementary Data). (Supplementary Data).

Study Characteristics
The studies included in this systematic review and meta- Discussion
analysis were published between 1986 and 2018. The The evidence supporting the effectiveness of exercise on
studies included a total of 1,221 participants, one study MTP-related dysfunctions is inconsistent. Our systematic
[41] focused on men only, and two studies [42, 43] in- review and meta-analysis aimed to synthesize the evi-
cluded women only. The mean age of participants ranged dence about the effect of PE programs on different MTP
from 15 to 76.5 years (Table 1). dysfunctions. According to the most recent evidence [63],
Table 1. Characteristics of the studies included in the systematic review and meta-analysis
4

Study Region Evaluated No. by Group (Women) Age, Mean 6 SD, y Intervention Length of Intervention Outcome Measures
Acar and Yilmaz (2012) Cervical IG1: 20 (17) 35.70 6 11.12 IG1: hot pack þ US þ stretching 5/wk Pain: SF-MPQ
IG2: 20 (17) 38.55 6 13.04 þ strengthening and postural 2 wk Connective tissue mobility: skin-
CG: 20 (17) 37.50 6 10.45 exercises roll test
IG2: stretching þ strengthening
and postural exercises
CG: NT
Buttagat et al. (2016) Scapular IG: 18 (12) 19.95 6 1.05 IG1: stretching þ stabilization 3 sets (10) Pain: VAS
CG: 18 (9) 21.20 6 1.80 exercises 3/wk PPT: algometer
CG: NT 4 wk Muscular tension: VAS
Anxiety: STAI
Carlson et al. (2001) Facial IG1: 23 (NR) 34.6 IG1: consuelling þ muscle relax- 2 sessions in 3 wk Pain: VAS, MPI
IG2: 21 (NR) ation þ proprioceptive training ROM: mm ruler
þ physical activity þ diaphrag- Psychological state: SCL-90-R
matic breathing Fatigue: Likert-scale
IG2: consuelling þ splint Affective distress: MPI
Sleep quality: PSQI
Cho et al. (2012) Shoulder IG1: 12 (NR) 48.08 6 12.24 IG1: stabilization exercises 3/wk Pain: VAS, CMS
IG2: 12 (NR) 47.67 6 10.49 IG2: ESWT þ stabilization 4 wk PPT: algometer
IG3: 12 (NR) 47.06 6 13.53 exercises ROM: CMS
IG3: ESWT Strength: CMS
Disability: NDI
Shoulder functionality: CMS
Crockett et al. (1986) Facial IG1: 7 (7) >19 y IG1: splint þ hot/cold applica- 7/wk 8 wk Pain: Likert-scale, MPQ
IG2: 7 (7) tions þ postural correction þ PPT: Likert scale
IG3: 7 (7) exercises for the jaw ROM: mm
IG2: muscle relaxation Electromyographic activity:
IG3: TENS EMG
Eftekharsadat et al. (2018) Cervical and shoulder IG1: 30 (28) 23.3 6 7.0 IG1: acupuncture 50 min Pain: VAS
IG2: 31 (27) 33.7 6 5.8 IG2: acupuncture þ aerobic 3/wk PPT: algometer
exercise 10 wk Disability: NDI
Quality of life: QoL-SF36
FranC¸a et al. (2008) Cervical and shoulder IG1: 15 (3.75) 38.0 6 10.0 IG1: acupuncture 20 min Pain: VAS
IG2: 15 (3.75) 30.0 6 13.0 IG2: stretching þ neck/upper 1–2 wk Muscular tension: VAS
IG3: 16 (3.69) 33.0 6 15.0 limbs strength exercises 10 wk Disability: NDI-BR
IG3: combination Cervical flexor muscles recruit-
ment patterns: bio-feedback
device
Gam et al. (1998) Cervical and shoulder IG1: 18 (NR) Median: 39.5 IG1: US þ massage þ stretching wk 1: 30 min Number of MTPs: palpation
IG2: 22 (NR) Median: 42 þ mobility and strength wk 2–4: 15 min Pain: VAS, analgesic usage
CG: 18 (NR) Median: 38.5 exercises 3/wk PPT: palpation (0–3)
Guzma

IG2: sham US þ massage þ 4 wk

stretching þ mobility
and strength exercises
 n-Pavo

CG: NT

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Table 1. continued
Study Region Evaluated No. by Group (Women) Age, Mean 6 SD, y Intervention Length of Intervention Outcome Measures
Gavish et al. (2006) Facial IG: 10 (10) 27.1 6 10.1 IG: chewing exercise wk 1–2: 10 min Pain: VAS, PRS
CG: 10 (10) 27.3 6 5.9 CG: consuelling wk 3–4: 15 min PPT: palpation (0–3)
wk 5–6: 20 min Disability: disability scale
wk 7–8: 30 min
3/d
8 wk
Hanten et al. (1997) Cervical and scapular 60 (42) 29.9 6 9.2 IG1: occipital relaxation 1 session PPT: algometer
IG2: active head exercises
CG: NT
Hanten et al. (2000) Cervical and upper 40 (23) 30.6 6 9.3 IG1: IC þ stretching 2/d Pain: VAS, % of time in pain
back IG2: active neck exercises 5d PPT: algometer
Jagdhari et al. (2017) Cervical IG1: 12 (NR) 15–60 IG1: resisted jaw exercises þ 2/d Pain: VAS
IG2: 20 (NR) strengthening exercises of the 4 wk PPT: palpation (0–3)
Effect of Exercise on Myofascial Pain

IG3: 14 (NR) neck and upper back muscles ROM: mm

IG2: LASER
IG3: combination
Jyothirmai et al. (2015) Cervical IG1: 15 (NR) 18–35 IG1: INIT þ stretching þ neck 15 min Pain: VAS
IG2: 15 (NR) strength exercises 14 sessions ROM: goniometer
IG2: INIT 4 wk Disability: NDI
Lee et al. (2013) Shoulder IG1: 16 (9) 48.1 6 13.2 IG1: hot pack þ US þ TENS þ 3 sets of 5 (each exercise) Pain: VAS, CMS
IG2: 16 (12) 47.7 6 10.7 muscle relaxation PPT: algometer
þ shoulder and scapular stabili- ROM: CMS
zation exercises Disability: NDI
IG2: hot pack þ US þ TENS Shoulder functionality: CMS
Lee (2014) Shoulder IG1: 5 (NR) 25.2 6 0.8 IG1: aerobic exercise (walk at 40 min PPT: algometer
IG2: 5 (NR) 71.2 6 05.3 6.5 km/h)
CG: 5 (NR) 24.3 6 0.5 IG2: strengthening exercises
CG: NT
Lugo et al. (2016) Cervical and shoulder IG1: 43 (36) 42.6 6 9.7 IG1: hot pack þ US þ compres- 3/wk Pain: VAS, SF-36
IG2: 43 (33) 37.7 6 11.8 sion þ stretching 4 wk Quality of life: SF-36
IG3: 41 (35) 37.2 6 11.1 þ mobility and strength exercises Depression: PHQ-9
for the cervical and shoulder
girdle
IG2: lidocaine injection
IG3: combination
Michelotti et al. (2000) Facial IG: 19 (15) 27.4 IG: consuelling þ massage þ 6/d Pain: VAS, scale (0–4)
CG: 13 (11) stretching þ 7/wk PPT: palpation (0–4)
coordination and strength 12 wk
exercises
CG: consuelling
Michelotti et al. (2004) Facial IG: 26 (21) 26.4 6 8.4 IG: consuelling þ muscular re- 20 Number of MTPs: palpation
CG: 23 (21) 32.6 6 13.7 laxation with diaphragmatic 3/d Pain: VAS
breathing þ massage þ heat 12 wk ROM: mm
pads PPT: algometer
þ stretching þ mandibular coor-
dination exercises
CG: consuelling
5

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Table 1. continued
6

Study Region Evaluated No. by Group (Women) Age, Mean 6 SD, y Intervention Length of Intervention Outcome Measures
Mulet et al. (2007) Facial IG: 20 (19) 25.1 6 2.3 IG: consuelling þ muscular re- 6 (each exercise) Pain: NGRS, VRS
CG: 22 (21) 23.4 6 2.1 laxation with diaphragmatic 6/d Posture: distance shoulder-to-ear,
breathing þ postural, active 4 wk neck angle, cranial angle
and control exercisesCG:
consuelling
Pereira et al. (2013) Forearm, arm, cervi- IG: 44 (NR) 28.7 6 8.8 IG: stretching þ muscular endur- 10 min 2/d Pain: Trigger Points Test
cal, fingers, lumbar, CG: 17 (NR) 27.8 6 7.4 ance þ relaxation þ massage 5/wk questionnaire
hands, shoulders, þ group dynamicCG: NT 24 wk
wrists, thorax
Quinn et al. (2016) Hip IG1: 33 (NR) 20 6 1.5 IG1: IC þ stretching 50 each side ROM: Modified Thomas Test
IG2: 33 (NR) 20 6 2.0 IG2: IC þ stretching þ medicine Measures of biomechanics and
CG: 33 (NR) 20 6 2.0 ball exercise golf performance
CG: NT
Tüzün et al. (2017) Low back IG1: 18 (8) 50.1 6 11.8 IG1: dry needling þ massage 3 sets of 10 (each exercise) Number of MTPs: palpation
IG2: 16 (12) 50.9 6 12.5 IG2: hot pack þ TENS þ US þ 2/d Pain: SF-MPQ, VAS
stretching þ strength exercises 3 wk PPT: palpation (0–2)
in abdomen and back muscles Depression: BDI
Kinesiophobia: TSK
Van Grootel et al. (2017) Facial IG1: 37 (95) 31.4 6 9.6 IG1: consuelling þ relaxation þ 2–3/wk Pain: VAS
IG2: 35 (91) 29.0 6 9.6 massage þ stretching þ pos- 9 wk
tural, proprioceptive and
strength exercises
IG2: splint
Wright et al. (2000) Facial IG: 30 (26) 32.7 IG: consuelling þ postural 30 min Pain: SSI
CG: 30 (25) 30.8 exercises 4 wk PPT: algometer
CG: consuelling ROM: mm

BDI ¼ Beck Depression Inventory; C-CFT ¼ cranio-cervical flexion test; CG ¼ control group; CMS ¼ Constant-Murley Scale; EMG ¼ electromyography; ESWT ¼ extracorporeal shock wave therapy; IC ¼ ischemic compres-
sion; IG ¼ intervention group; INIT ¼ integrated neuromuscular inhibitory technique; LASER ¼ light amplification by stimulated emission of radiation; MPI ¼ Multidimensional Pain Inventory; MPQ ¼ McGill Pain
Questionnaire; MTP ¼ myofascial trigger point; NDI ¼ Neck Disability Index; NDI-BR ¼ Brazilian Portuguese version of the Neck Disability Index; NGRS ¼ numerical graphic rating scale; NR ¼ not reported; NT ¼ no treat-
ment; PHQ-9 ¼ Patient Health Questionnaire; PPT ¼ pressure pain threshold; PRS ¼ Pain Relief Scale; PSQI ¼ Pittsburgh Sleep Quality Index; QoL-SF36 ¼ Quality of Life SF-36 Questionnaire; ROM ¼ range of movement;
SCL-90-R ¼ Revised Symptom Checklist–90; SF36 ¼ SF-36 Questionnaire; SF-MPQ ¼ Short-Form McGill Pain Questionnaire; SSI ¼ Symptom Severity Index; STAI ¼ State Anxiety Inventory; TENS ¼ transcutaneous electrical
nerve stimulation; TSK ¼ Tampa Scale of Kinesiophobia; US ¼ ultrasound; VAS ¼ visual analog scale; VRS ¼ verbal rating scale.
Guzma
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Effect of Exercise on Myofascial Pain 7

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Figure 1. Forest plot for the effect of physical exercise on pain intensity.

the findings of this systematic review and meta-analysis Our results show that PE is effective in reducing pain
support that PE is effective in reducing pain intensity and intensity and increasing the pressure pain threshold.
increasing the pressure pain threshold and range of mo- These findings are in line with those of previous studies
tion; however, no evidence on reducing disability in reporting exercise benefits as compared with no interven-
patients with MTPs was observed. tion [61] or interventions such as support and encourage-
PE is usually linked with stretching, aerobic, and ment [42], LASER [49], TENS [43], or lidocaine
strength exercises. However, other types of exercise have injection [51]. Several pathophysiological mechanisms
been proposed, such as postural, proprioceptive, coordina- have been proposed to explain the positive effect of PE
tion, and stabilization interventions. It has been postulated on MTPs, such as the counteracting effect of the local is-
that postural changes are one of the factors involved in the chemia of MTPs caused by the sustained contraction of
development and perpetuation of MTPs by altering the nor- sarcomeres, which stimulates the release of the sensitizing
mal anatomic relationships [56]. Specific proprioceptive substances that produce nociception [7]. The muscular
training regimes are designed to target the deep muscles as contraction performed during PE could favor the blood
they have the highest density of receptors and are known to supply and drainage of sensitizing substances present in
have a specific role in reflex and central connections to the the MTP environment, and therefore reduce the central
vestibular, visual, and postural control systems. and peripheral sensitizations that cause local and/or re-
Additionally, coordination exercises have been advocated ferred pain [11]. Finally, the abnormal tension of the taut
for addressing impaired neuromuscular control [64]. bands where MTPs are located is responsible for the fre-
Finally, stabilization exercises are proposed to enhance the quent existence of mobility restriction [65]. Muscle con-
strength of the postural muscles, stabilizing the muscles and traction could cause localized stretching of MTPs and,
increasing the stability of the relevant joints [60]. Despite thereby, normalization of the sarcomeres [19].
their potentially interesting effects, studies assessing the ef- Conversely, although all the studies including disabil-
fectiveness of these techniques in the treatment of MTPs are ity as an outcome reported a positive effect on reducing
scarce, so further studies are needed to show the efficacy of disability [24, 27, 28, 32, 41, 42], the pooled estimates
these approaches in the treatment of MTPs. did not achieve statistical significance. As pain is one of
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Figure 2. Forest plot for the effect of physical exercise on pressure pain threshold.

Figure 3. Forest plot for the effect of physical exercise on range of motion.
Effect of Exercise on Myofascial Pain 9

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Figure 4. Forest plot for the effect of physical exercise on disability.

the most important causes of disability in MPS patients, treatment of MTPs should be personalized considering
the lack of data on the outcome of included studies the individual characteristics of the patient and associ-
reporting high ES on pain reduction may be behind the ated pathologies.
observed lack of statistical power. The apparent mis-
match between the effect of PE interventions on pain in-
tensity and disability could also be due to the Conclusions
biopsychosocial characteristics of patients, such as gen- PE may be an effective therapeutic strategy for reducing
der, occupational factors, anxiety, and fear, which may pain intensity while increasing pressure pain threshold
act as mediators of effect modifiers on the relationship and range of motion in individuals with MTPs. Future
between pain and functional capacity [65]. Moreover, studies should investigate the effects of PE programs on
longer interventions and follow-up periods may be other clinical outcomes, such as quality of life, and use
needed to observe changes in patients’ disability percep- standard criteria for the diagnosis of MTPs.
tion. This is because the consequences of pain and dis- Additionally, a detailed description of the PE interven-
ability, such as depression, may have a negative influence tion’s characteristics for the treatment of MTPs is neces-
on this perception and may continue after improvements sary in order to better adapt these programs to the
in pain or pressure pain threshold.
patients’ characteristics and possible associated
Some limitations of this study should be acknowl-
pathologies.
edged. First, the selection of studies addressing the assess-
ment of the effectiveness of PE in the treatment of MTPs
may be incomplete, as gray literature sources were not in- Supplementary Data
cluded. Second, the diagnosis of MTPs was not always Supplementary data are available at Pain Medicine online.
clear due to the lack of a standard criterion and because
the identification of taut bands and MTPs requires expe-
rience among examiners. To minimize this limitation, References
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