EFFECT OF ISCHEMIC COMPRESSION ON TRIGGER POINTS IN

THE NECK AND SHOULDER MUSCLES IN OFFICE WORKERS: A

COHORT STUDY
Barbara Cagnie, PT, PhD, a Vincent Dewitte, PT, b Iris Coppieters, PT, b Jessica Van Oosterwijck, PhD, c
Ann Cools, PhD, d and Lieven Danneels, PhD e

ABSTRACT

Objective: The purpose of this study was to determine the short-term effect of ischemic compression (IC) for trigger
points (TPs) on muscle strength, mobility, pain sensitivity, and disability in office workers and the effect on disability
and general pain at 6-month follow-up.
Methods: Nineteen office workers with mild neck and shoulder complaints received 8 sessions of IC in which deep
pressure was given on the 4 most painful TPs identified during examination. Outcome measures were general neck
and shoulder complaints on a Numeric Rating Scale, Neck Disability Index (NDI), neck mobility (inclinometer),
muscle strength (dynamometer), and pain sensitivity (Numeric Rating Scale and algometry). Subjects were tested at
baseline (precontrol), after a control period of no treatment of 4 weeks (postcontrol), and after a 4-week intervention
training (posttreatment). At 6-month follow-up, pain and disability were inquired.
Results: The results showed a statistically significant decrease in general neck/shoulder pain at posttreatment (P =
.001) and at 6-month follow-up (P = .003) compared with precontrol and postcontrol. There was no significant main
effect for NDI scores. Pressure pain threshold increased at posttreatment in all 4 treated TPs (P b .001). There was a
significant increase in mobility and strength from precontrol/postcontrol to posttreatment (P b .05).
Conclusion: This study has demonstrated that a 4-week treatment of TPs for IC resulted in a significant improvement
in general neck and shoulder complaints, pressure pain sensitivity, mobility, and muscle strength in the short term in a
small sample of office workers with mildly severe chronic pain. At 6-month follow-up, there was a further decrease in
general pain, but no change in NDI scores. (J Manipulative Physiol Ther 2013;36:482-489)
Key Indexing Terms: Muscles; Trigger Points; Myofascial Pain Syndromes; Muscle Strength; Range of Motion

ork-related neck and shoulder pain is an work imposes prolonged low-level static exertions as well as

W ongoing and increasing problem in office

workers. Its etiology is multifactorial as this
high visual, postural, and cognitive stress. 1 A common
finding in the worker population is the presence of myo-
fascial trigger points (TPs). 2-5 They are considered as
hyperirritable and sensitive palpable nodules in a taut band
a
Assistant Professor, Department of Rehabilitation Sciences of a skeletal muscle or muscle fascia, which may cause
and Physiotherapy, Ghent University, Ghent, Belgium. numerous sensory, motor, neurologic, and autonomic symp-
b
Doctoral Researcher, Department of Rehabilitation Sciences
and Physiotherapy, Ghent University, Ghent, Belgium. toms. 6 The key clinical signs and symptoms of TPs are local
c
Doctoral Researcher, Department of Rehabilitation Sciences and referred pain, restricted ranges of motion (ROMs) with
and Physiotherapy, Ghent University, Ghent, Belgium. increased sensitivity to stretching, and muscle weakness
d
Associate Professor, Department of Rehabilitation Sciences due to pain with no muscular atrophy. 7
and Physiotherapy, Ghent University, Ghent, Belgium. The upper trapezius is often clinically indicated as the
e
Full Professor, Department of Rehabilitation Sciences and
Physiotherapy, Ghent University, Ghent, Belgium. muscle of interest in office workers, which is also reflected
Submit requests for reprints to: Barbara Cagnie, PT, PhD, in the amount of research that is focused on this muscle. 8-17
Assistant Professor, De Pintelaan 185 3B3, 9000 Ghent, Belgium However, other muscles of the neck/shoulder complex may
(e-mail: [email protected]). be affected as well and should, therefore, not be overlooked
Paper submitted January 14, 2013; in revised form May 14, when treating neck/shoulder pain. Andersen et al 18 recently
2013; accepted May 24, 2013.
0161-4754/$36.00 demonstrated a high prevalence of severe tenderness in the
Copyright © 2013 by National University of Health Sciences. levator scapulae, neck extensors, and infraspinatus muscle
http://dx.doi.org/10.1016/j.jmpt.2013.07.001 as well in this population.

482
Journal of Manipulative and Physiological Therapeutics Cagnie et al 483
Volume 36, Number 8 Trigger Point Therapy for Office Workers

Table 1. Anthropometric data questionnaire. This questionnaire was a shortened version

Mean SD of the standardized “Dutch Musculoskeletal Question-
Age (y) 39.5 8.32 naire,” including the Neck Disability Index (NDI) to assess
Duration of employment (y) 13.1 7.7 self-perceived disability and general neck/shoulder pain
Working hours per week (h) 39.1 5.1 experienced in the preceding week on a 11-point Numeric
NDI (points/50) 8.2 3.4 Rating Scale (NRS) (0, no pain; 10, worst possible
NRS (points/10) 4.8 2.5
pain). 1,29 Subjects were then tested on pain sensitivity,
NDI, neck disability index; NRS, numeric rating scale. mobility, and muscle strength (precontrol) (see below). This
test protocol, completed with the NDI and general neck/
There are a variety of modalities purported to relieve or shoulder pain score, was repeated 4 weeks after the first
diminish the symptoms associated with TPs with most studies testing session (postcontrol). During this 4-week period,
focusing on the effect of treatment on pain relief. 19-22 A subjects were not allowed to have any treatment for their
frequently applied manual pressure technique is ischemic neck/shoulder pain. Subjects then received 8 sessions of
compression (IC), that is, application of increasing pressure treatment (4 weeks, 2 times a week), consisting of IC on the
on the TPs, usually with the thumb, until the pain reaches its 4 most painful TPs selected during the first testing session
maximal tolerable level. A recent review of the literature (see below). No other treatment was allowed during this
demonstrated a moderately strong evidence supporting the period. After this treatment, patients were tested again on all
use of ischemic pressure for immediate pain relief at TPs, but aforementioned parameters (posttreatment). At 6-month
only limited evidence for long-term pain relief. 23 There are, follow-up, subjects were asked to complete the NDI and
however, only a limited amount of randomized controlled their general pain score (NRS). Both measurements and
trials with a sufficiently high quality score. 19-22 treatment sessions took place in a clinical setting, that is, at
In addition to pain relief, studies evaluating the effect of the workplace of the patients.
ischemic pressure on ROM and strength are sparse. Only a
few studies have demonstrated an increase in ROM 20,24-28
Testing Protocol
and gain in strength 28 after a single or multisession treat-
All tests were performed by a trained examiner who
ment of IC. It was hypothesized that a multisession treat-
was blinded to the questionnaire replies on self-reported
ment of IC on neck and shoulder muscles would have a
pain symptoms.
short-term improvement in pain, mobility, and strength and
a long-term improvement in pain and ability to manage Pressure Pain Sensitivity. Pressure pain sensitivity was deter-
everyday life activities. Therefore, the purpose of this mined by deep palpation of 6 anatomical neck/shoulder
study was to evaluate the effect of IC on TPs in neck and locations on the left and right side: upper and lower trapezius
shoulder muscles on disability, pain, mobility, and muscle muscle, levator scapulae muscle, splenius cervicis muscle,
strength in office workers over time. and supraspinatus and infraspinatus muscle. Palpation was
performed according to the instructions of Andersen et al. 18
METHODS Subjects were asked to rate their pain on an NRS from 0 to
10, for each anatomical location. Based on this rating, the 4
Study Population
most painful points were selected for evaluation of pressure
Twenty-seven right-handed office workers performing at
pain threshold (PPT) by use of an electronic algometer
least 4 hours of computer work as part of their daily job duties
(compuFET; Hoggan Health Industries, Inc, West Jordan,
were recruited from 2 different companies from October 2012
UT). The PPT is the force (N) needed to give the amount of
to December 2012. Subjects with a history of traumatic
pressure that causes a changeover from sensitivity to pain in
injuries or surgical interventions of the neck or upper limb
the subject. One trial was executed for each point tested. The
regions were excluded. The subjects were included if they
interrater and intrarater reliability of algometry has been
met the following criteria: (1) neck/shoulder pain or
found to be moderate to high (intraclass correlation
discomfort of more than 30 days during the last year in the
coefficient ranging from 0.75-0.84). 30
neck or shoulder region, (2) pain frequency of at least once a
week, and (3) an intensity of pain of at least 2 on a scale from Passive Cervical ROM. Neck mobility was evaluated using a
0 to 10. Anthropometric data are presented in Table 1. digital inclinometer (ACUMAR Digital Inclinometer, ACU
All subjects provided informed and signed consent 360; Lafayette Instrument Company, Lafayette, IN). Sub-
before inclusion in the study. The study was approved by jects were instructed to sit upright, relax their shoulders, and
the Local Ethics Committee of Ghent University Hospital. rest their hand on their thighs, whit hips, and knees flexed at
90°. The goniometer was place on the top of the head, and
the patient was asked to move the head as far as possible
General Design of the Study with overpressure at the end of range by the therapist. A
The general design is illustrated in Figure 1. Before the standard sequence of movements was used: flexion,
testing, the subjects were asked to complete an online extension, and right and left side bending. The value for 3
484 Cagnie et al Journal of Manipulative and Physiological Therapeutics
Trigger Point Therapy for Office Workers October 2013

Fig 1. Muscle strength measurements: empty can strength test (supraspinatus and upper trapezius) (A), isometric exorotation
(infraspinatus) (B), shoulder elevation (upper trapezius and levator scapulae) (C), and head extension (splenius cervicis) (D).

trials were recorded for each direction of movement, and the Ischemic compression consisted of pressure that was
measurements in the sagittal plane (flexion-extension) were gradually increased until the subject experienced his/her
combined for further analyses as well as left and right side highest tolerable pain. This pressure was sustained for 1
bending in the frontal plane.. This protocol of measuring minute. This intervention was carried out 2 times a week,
ROM has been shown to have good reliability. 31 for 4 weeks (8 treatments in total).
Muscle Strength. Muscle strength tests were manually
performed with a dynamometer (compuFET). Strength
Statistical Analysis
was measured on both sides: empty can strength test (for
Analysis was performed using the SPSS statistics 19.
supraspinatus and upper trapezius), isometric exorotation
Normality was assessed by means of the Kolmogorov-
(for infraspinatus), shoulder elevation (for upper trapezius
Smirnov Z test (P N .05), which indicated that parametric
and levator scapulae), and head extension strength test (for
statistics could be applied. Descriptive statistics (mean and
Splenius cervicis) (Fig 1). Each test was repeated 3 times,
SD) were calculated for all parameters. Analyses of
and the mean was calculated. This method of testing has
shown high test-retest and intertester reliability. 32 variance with repeated measures were applied for each
parameter. Within-subjects factor for all parameters was
time (precontrol, postcontrol, and posttreatment; follow-up
Intervention was added for NDI and NRS). Body side was additionally
The subjects were seated in a relaxed position with the included as a within-subject factor for pain sensitivity by
forearms supported on the table. The intervention consisted NRS and strength. Post hoc pair-wise comparisons were
of IC on the 4 individually determined most painful TPs. made when required, and adjustments were used to correct
Journal of Manipulative and Physiological Therapeutics Cagnie et al 485
Volume 36, Number 8 Trigger Point Therapy for Office Workers

Fig 3. Results of neck disability index (NDI) at precontrol,

postcontrol, posttreatment, and 6-month follow-up.

Fig 2. Flowchart of the study design.

for multiple tests (Bonferroni). Statistical significance was

accepted at the .05 α level.

RESULTS
Subjects
As illustrated in Figure 2, 8 subjects dropped out during
the course of the study. The reason for drop out was illness or
election not to complete the study. Nineteen subjects (16
females and 3 males; mean age, 39.47 ± 8.32 years) Fig 4. Results of general pain score (NRS) at precontrol,
postcontrol, posttreatment, and 6-month follow-up. Asterisk
completed the study and were included for the analyses. denotes significant differences between precontrol/postcontrol
Their mean duration of employment was 13.1 (± 7.7) years and posttreatment and 6-month follow-up (P b .05).
with a mean of 39.1 (± 5.1) working hours per week. No
adverse events were reported during this study.
Mobility
Disability (NDI) and General Neck and Shoulder Pain (NRS) There was a significant main effect for time for both
There was no significant difference between all test flexion-extension (F = 7.281; P = .003) and side flexion
moments for disability (F = 2.817; P = .079) (Fig 3). (F = 13.238; P ≤ .001). Both directions increased in
There was a significant difference in NRS score for mobility from precontrol/postcontrol to posttreatment (Fig 6).
general neck and shoulder pain between the different test
moments (F = 13.277, P b .001). The NRS score was Muscle Strength
similar between precontrol and postcontrol (P = .333) but Table 2 represents the analyses of variance for all strength
decreased at posttreatment (P = .001) and at 6-month tests. There was a significant main effect for time for all tests
follow-up (P = .003) (Fig 4). and a significant main effect for side only for the empty can
Pressure Pain Sensitivity test. All strength scores were significantly higher at
posttreatment compared with precontrol and/or postcontrol.
Of the 4 most painful TPs, 68.4% was located in the
right upper trapezius; 42.1%, in any of the left upper
trapezius, right levator scapulae, or right splenius cervicis. DISCUSSION
Analyses of variance evaluating the effect of treatment on The purpose of this study was to evaluate the effect of IC
the 4 most painful points revealed a main effect for time on TPs in neck and shoulder muscles on disability, pain,
for each muscle (F = 71.304; P b .001), with an increase in mobility, and muscle strength in office workers. This study
PPT at posttreatment compared with precontrol/postcontrol has demonstrated that a 4-week treatment of TPs with IC
(P b .001) (Fig 5). resulted in a significant improvement in general neck and
486 Cagnie et al Journal of Manipulative and Physiological Therapeutics
Trigger Point Therapy for Office Workers October 2013

Fig 6. Range of motion (°) (flexion-extension and side bending) at

precontrol, postcontrol, and posttreatment. Asterisk denotes
Fig 5. Pressure pain threshold (N) in the 4 most painful TPs significant differences between precontrol/postcontrol and post-
(MP1-MP4) at precontrol, postcontrol, and posttreatment. treatment (P b .05).
Asterisk denotes significant differences between precontrol/
postcontrol and posttreatment (P b .001).
Pressure pain threshold increased for all 4 most painful
shoulder complaints, pressure pain sensitivity, mobility, muscles after a 4-week treatment on these muscles. This is
and muscle strength in the short term in a small sample of in agreement with previous studies investigating the effect
mildly severe chronic pain patients. At 6-month follow-up, of IP on PPT, although most of these studies have
there was a further decrease in general pain, but no change investigated the effect of a single session treatment. 20,27
in NDI scores. Several mechanisms have been proposed to explain the
Although NDI scores of the subjects improved over time, effect of IC on PPT. Pain relief from ischemic
this improvement was not significant. A possible cause for compression treatment may result from reactive hyperemia
this lack of significant improvement can be the low mean in the TP region, counterirritant effects, or a spinal reflex
baseline NDI-score. This score was 8.63, which indicates a mechanism for the relief of muscle spasm. 20 The pressure
study population with mild complaints. 11 Because of this, a that is applied to the TP should be within a tolerable pain
relative high improvement is needed to obtain clinically level for each patient to avoid causing excessive pain and
significant results. Other studies that examined the effect autonomic responses with involuntary muscle tensing.
of IC on disability confirm our results. 26,33 Although Simons et al 6 hypothesized that TPs can
The NRS score was similar between precontrol and induce restricted ROM in the tissues where they are
postcontrol but decreased significantly at posttreatment present, only a few studies have demonstrated a correlation
and at 6-month follow-up. The most painful TPs were between TPs and lack of mobility. Fernandez-Perez et al 35
located in the upper trapezius bilaterally, right levator found that the number of active TPs in the neck and
scapulae, and right splenius cervicis muscle, which is in shoulder muscles in subjects with whiplash-associated
accordance with some recent studies that showed also high disorders was associated with a reduction of cervical ROM.
prevalence of severe tenderness in the levator scapulae, In the present study, ROM improved significantly in
neck extensors, and infraspinatus. 2,18 Other studies have both directions after treatment with IC, which is also in
also indicated the short-term effect of ischemic compres- agreement with previous studies. 25-27,36 Sarrafzadeh et al 25
sion on pain intensity. 19-22,26 Apart from the statistically investigated the effect of pressure release on upper
significant changes, it is even more important to consider trapezius on active cervical lateral flexion and found an
the clinical significance of the results. The minimal increase in motion after 6 sessions of treatment compared
clinical important difference for NRS is, pending on the with a control group. Grieve et al 36 evaluated the
studies, a decrease of 1.5 points or a decrease of 30% immediate effect of soleus trigger point pressure release
from baseline value. 34 We can conclude that the change in on restricted ankle join dorsiflexion and found an increase
pain intensity, both at posttreatment and follow-up, was in ankle ROM in the intervention group compared with the
clinically significant. As previously remarked, most re- control group. Nagrale et al 26 used a combined treatment
search is focused on the upper trapezius. This study approach, including IC, demonstrating a significantly
further highlights the need for research studies investigat- greater improvement in lateral cervical flexion ROM after
ing other neck/shoulder muscles such as levator scapulae treatment. A possible explanation for the increased ROM
and neck extensors. after IC is that manual pressure on the contraction knot of
Journal of Manipulative and Physiological Therapeutics Cagnie et al 487
Volume 36, Number 8 Trigger Point Therapy for Office Workers

Table 2. Results of muscle strength measurement at precontrol, postcontrol, and posttreatment

Precontrol Postcontrol Posttreatment F P
Strength (N) Empty can test
Right 84.3 (±24.7) 86.1 (± 16.8) 100.2 (±30.9) a 5.182 .011
Left 88.8 (±26.3) 93.5 (± 22.8) 107.0 (±33.8) a 4.610 .022
Exorotation test 83.6 (±17.7) 85.8 (± 17.6) 95.4 (± 18.8)a,b 14.997 ≤.001
Shoulder elevation test 226.6 (± 51.3) 219.4 (± 49.8) 249.2 (±49.3) b 4.891 .016
Head extension test 100.4 (± 26.6) 109.6 (± 19.5) 123.8 (±35.2)a,b 10.119 .001
a
Significant at 0.05 between precontrol and posttreatment.
b
Significant at 0.05 between postcontrol and posttreatment.

the TP causes lengthening of the sarcomeres. Decrease of Further studies with larger samples and with control
abnormal tension of the taut band and general pain reduc- groups are necessary to investigate the best parameters and
tion may also contribute to an increased ROM. 7,37 long-term effects of IC on these outcome measures in com-
Only a few studies have investigated the relationship puter workers.
between TPs and strength. Celik and Yeldan 38 demon-
strated a significantly lower muscle strength for flexion
and scaption in subjects with at least 2 TPs in neck/ CONCLUSION
shoulder muscles, compared with subjects with no TPs. In conclusion, this study has demonstrated that a 4-week
Wytrazeck et al 39 demonstrated that the presence of TPs treatment of TPs with IC resulted in a significant improve-
was accompanied by decreased muscle strength. To the ment in general neck and shoulder complaints, pressure pain
best of our knowledge, studies investigating the effect of sensitivity, mobility, and muscle strength in the short term in
IC on TPs are lacking. The results of this study show a a small sample of office workers with mildly severe chronic
statistically significant improvement of the muscle pain. At 6-month follow-up, there was a further decrease in
strength of different neck and shoulder muscles. A general pain, but no change in NDI scores.
possible explanation may be that the shortened sarcomeres
are lengthened by IC and may participate again in the
contraction of the involved muscle. The vicious cycle and
reflex inhibition are also interrupted by IC. The theory is Practical Applications
that reactive hyperemia after the application of IC may • The results showed a statistically significant
lead to a better oxygen supply and less production of decrease in general neck/shoulder pain at
nociceptive and inflammatory substances, resulting in less posttreatment and at 6-month follow-up.
damage of the muscle fibers and, consequently, better • There was a significant increase in mobility
strength production. 9 and strength from precontrol/postcontrol to
posttreatment.
Study Limitations • Ischemic compression may be an added value
The present results must be viewed within the in the treatment of myofascial pain in neck
limitations of the study. The first limitation is the small and shoulder muscles in office workers.
sample size. Secondly, subjects only had mild functional
complaints, possibly explaining the nonsignificant changes
in disability. Thirdly, the study design in which subjects
served as their own control may have some limitations. In ACKNOWLEDGMENT
addition to learning effect and the effect of spontaneous The authors thank Ms Elise Buyse, Ms Katrijn D’hondt,
improvement of the complaints over time, lacking a and Ms Justine Vercruysse for their assistance in collecting
control group may also imply that the effects of treatments the data
found in the results could be attributed to the nonspecific
effects of treatment. In addition, the fact that a pragmatic FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
approach was used in which the treated TPs were selected
based on their PPT and were, as a consequence, not No funding sources or conflicts of interest were reported
similar in all subjects made interpretation more difficult. for this study.
On the other hand, this way of treating patients more
resembles clinical practice. A last limitation is the fact CONTRIBUTORSHIP INFORMATION
that, although no other treatments were allowed during the
study duration, there was no specific procedure to evaluate Concept development (provided idea for the research):
if participants did comply with these instructions. BC, VD, IC, JV, AC, LD
488 Cagnie et al Journal of Manipulative and Physiological Therapeutics
Trigger Point Therapy for Office Workers October 2013

Design (planned the methods to generate the results): 11. Szeto GPY, Straker LM, OÆSullivan PB. Examining the
low, high and range measures of muscle activity amplitudes
BC, VD, IC, JV, AC, LD in symptomatic and asymptomatic computer users perform-
Supervision(providedoversight,responsiblefororganization ing typing and mousing tasks. Eur J Appl Physiol 2009;106:
and implementation, writing of the manuscript): 243-51.
BC, VD, IC, JV, AC, LD 12. Delisle A, Lariviere C, Plamondon A, Salazar E. Reliability of
different thresholds for defining muscular rest of the trapezius
Data collection/processing (responsible for experiments, muscles in computer office workers. Ergonomics 2009;52:
patient management, organization, or reporting data): 860-71.
BC, VD, IC, JV, AC, LD 13. Delisle A, Lariviere C, Plamondon A, Imbeau D. Comparison
Analysis/interpretation (responsible for statistical analy of three computer office workstations offering forearm
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Ergonomics 2006;49:139-60.
BC, VD, IC, JV, AC, LD
14. Dumas GA, Upjohn TR, Leger A, et al. Effect of a desk
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BC, VD, IC, JV, AC, LD during computer work. Ergonomics 2008;51:1735-56.
Writing (responsible for writing a substantive part of the 15. Strom V, Roe C, Knardahl S. Work-induced pain, trapezius
manuscript): blood flux, and muscle activity in workers with chronic
shoulder and neck pain. Pain 2009;144:147-55.
BC, VD, IC, JV, AC, LD 16. Steingrimsdottir OA, Kopke VN, Knardahl S. A prospective
Critical review (revised manuscript for intellectual content, study of the relationship between musculoskeletal or psycho-
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