Positional Release Therapy and Therapeutic Massage Reduce Muscle Trigger and Tender Points
Phase: NA
Conditions: Trigger Point Pain, Myofascial
Sponsor: Brigham Young University

Cover Page 
 
Positional Release Therapy and Therapeutic Massage Reduce Muscle Trigger and Tender Points 
 
NCT #: Not yet assigned 
 
Todays date: 1/14/2021 
 
Study protocol and statistical analysis plan 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
INTRODUCTION  
Myofascial pain is a common disorder affecting individuals across the general population 
and in specific populations, such as athletes, resulting in compromised function, performance, 
and productivity (Muller et al., 2014).  It has been associated with many pain conditions 
including tension-type headache, spine disorder, and neck and shoulder pain (Muller et al., 
2014; Simons &  Travell, 1981). Myofascial pain characteristically results from hyperirritable 
nodules of muscle (trigger points or tender points) associated with pain in affected regions of the 
body (Jafri, 2014).  These areas within the muscle are subjected to continued contraction of 
muscle fibers due to “too much” calcium resulting in compromised oxygenation of the muscle 
tissue (Dommerholt et al., 2006). These hyperirritable nodules often occur in fatigued muscles 
that are subjected to imbalanced postural positions, such as the forward head and rounded 
shoulders postures (JG &  SH, 1983). It can also occur from repetitive movements commonly 
seen in athletics, and individuals performing manual work (Borg-Stein &  Simons, 2002).  
Positional release therapy (PRT) and therapeutic massage (TM) are methods used to treat 
trigger or tender points (D'Ambrogio &  Roth, 1997; Knight &  Draper, 2013; Wong, 
2012). Separate studies on each method have shown efficacy in reducing pain (Aboodarda et al., 
2015; Mohammadi Kojidi et al., 2016) muscle tightness (Kelencz et al., 2011) and improving 
joint mobility (D'Ambrogio &  Roth, 1997).  PRT is a manual therapeutic technique that first 
locates tender points within a muscle. Once identified, the practitioner places the muscle in a 
passively shortened position, while applying slight pressure (D'Ambrogio &  Roth, 1997). TM 
involves the manipulation of soft tissue using techniques such as effleurage and petrissage, to 
restore blood flow and oxygenation of the muscle tissue (Tessier, 2005; Yang et al., 2012).   

Various methods have previously been used to find and assess severity of tender or 
trigger points. Among those commonly used are the pressure pain algometer with pressure pain 
threshold (PPT), range of motion electromyography and visual analog scales (VAS) (Aboodarda 
et al., 2015; Buttagat et al., 2012; Draper, 2015; Ghanbari et al., 2012; Kelencz et al., 
2011; Nagrale et al., 2010; Simons &  Travell, 1981; Sweety et al., 2014; Wong, 
2012). Some studies have also utilized B-mode (two-dimensional) ultrasound imaging (US) to 
locate, define, trace, and quantify myofascial trigger points after palpation providing a useful 
means of quantification (Cojocaru MC, 2015; Kumbhare DA, 2016; Muller et al., 2014). Shear 
wave elastography ultrasound (SWE) has been used to calculate the elastic modulus (tissue 
stiffness) of muscle reliably, (Brandenburg et al., 2014; Eby et al., 2013; Gennisson et al., 
2010; Kumbhare DA, 2016; Muller et al., 2014), but has not been used quantify changes within 
trigger points following treatment.   
Objectives  
The purpose of our study was to quantify the effectiveness of PRT or TM at reducing 
pain, trigger point tenderness, and muscle stiffness in the upper trapezius muscle by using a 
combination of the visual analog scale, PPT, B-mode US and SWE to assess changes within 
triggers points.  

  
METHODS  
  
Participants  
We recruited 60 healthy Participants, 24 males and 36 females, (age=27.1±8.8 
years, wt=75.2±17.9 kg, ht= 172.8±9.7 cm) to participate in the study. Many of the participants 
participated on a University dance team. Participants admitted into the study were required to 

have upper trapezius pain, during palpation, of at least 10 mm on the 100mm visual analog 
scale and muscle tightness with an accompanying trigger point in their upper 
trapezius. Participants who had suffered an acute injury to their upper trapezius in the last 6 
days, were undergoing current treatment for their upper trapezius, or were unable to lie on their 
stomach for an extended amount of time were removed from the study.    
The study was approved by the university’s Institutional Review 
Board (IRB#17411) before participant recruitment. All participants provided written informed 
consent before individual data collection began.   
Instruments   
We used a GE LOGIC S8 ultrasound machine (4MDMedical, Lakewood, NJ) with the 9L 
soundhead to measure muscle thickness and stiffness. Muscle thickness was measured using B-
mode ultrasound and SWE measured stiffness of the tissue.   
In order to quantify subjective perception of pain we used PPT algometer (Jtech Medical 
Commander Echo pressure algometer, Jtech Medical, Midvale, UT) with a .5 cm2 applicator tip 
along with the 100 mm visual analog scale.    
Procedures   
Figure 1 outlines study procedures. During the first visit participants underwent screening 
for presence of inclusion and exclusion criteria as well as palpation for trigger points, following 
guidelines by Simons, Travell and Speicher (Simons &  Travell, 1981; Speicher, 2016). Each 
side was examined and pain produced during palpation was measured with previously published 
methods using the VAS (Crichton, 2001). The side that was to be treated was determined by the 
higher VAS score. Trigger point location, found through palpation, was marked so that all 
measurements were taken in the same location. All baseline measurements were taken 

according to the methods listed below. The participants were then randomly assigned into one of 
two treatment groups, one being positional release therapy, the other therapeutic massage.  
The same order of measurement was used for all participants since we felt that pressure 
from the PPT algometer could act as a treatment and influence the visual analog scale or 
elastography measures. Measurements were taken at rest with the participant in prone position, 
with their arms at their sides for all measurement series, before and after treatment.   
Pain Pressure Threshold   
Pain pressure threshold was determined by a digital pressure algometer on the same point 
identified during screening. The area was measured once by pressing perpendicularly into the 
trigger point until the subject declared it to be painful. The peak force measured was then 
recorded in kg.  
Ultrasound and Elastography  
The ultrasound machine with a 9L sound head was used to measure two different 
variables of muscle tension; 1) muscle thickness (B-mode) and tissue stiffness via SWE over the 
same spot found and marked during screening. Using B-mode on the ultrasound machine, two 
images aligned with the muscle fibers obtain were taken to obtain muscle thickness. Internal 
software was used to measure muscle thickness and the 2 images were averaged and recorded in 
cm. The elastography measure used a 3 cm2 box positioned over the area containing the trigger 
point. Nine sample circles of .5cm dimeter were set within the box side by side in rows in order 
to cover as much of the box as possible (shown in figure 1). (source?) Each circle registered a 
strain modulus reading in kPa.  The average of the 9 sample circles was used to represent the 
stiffness of the muscle in the data 

analysis. 
 
Treatment groups  
Therapeutic Massage  
Participants in the TM treatment group received a timed massage for 5 minutes by the 
same experienced research.  A combination of effleurage and petrissage techniques were used in 
an organized pattern. Treatment started with effleurage (1-1.5 minutes) and proceeded to 
petrissage (2.5 to 3 minutes) again followed by effleurage (1 minute) over the marked area of the 
trigger point, but also in some surrounding areas. The pressure applied by the researcher 
progressed throughout the massage into the petrissage phase as tolerated by the participant and 

pressure was then reduced during the final effleurage phase. After the treatment was completed, 
the same dependent variable measurements were taken.    
Positional Release Therapy  
Participants in the PRT group received three successive treatments or releases in the 
marked area. The researcher located the marked trigger point and while maintaining contact, a 
light pressure with the clinician’s fingertip was applied creating slight dimpling of the skin and 
blanching of the clinician’s fingernail bed. Following palpation, the researcher 
moved the participant’s shoulder into passive abduction and scapular upward rotation 
and retraction until a position of comfort was achieved with no pain reported by the participant, 
as directed by Speicher, “Clinical Guide to Positional Release Therapy” (Speicher, 
2016) (Figure 3). The participant was instructed to remain completely relaxed during the 90 
second treatment. After the recommended 90 seconds had passed the limb was returned to the 
starting position. This was repeated immediately 2 more times in tender points immediately 
adjacent to the first one, as recommended by Speicher (Speicher, 2016). Following treatment, the 
same dependent variable measurements were taken.  
 
Posttreatment measurements   
Each participant returned 48 hours post treatment, where dependent measurements were 
taken. Participants were also given an activity survey to record the number of hours they 
exercised between the last session and the current session to note any abnormalities or increase 
in normal exercise. The mark made from the first session, over the examined trigger point, 
was still visible at the second visit for all participants and was used to determine the location for 
performing dependent measurements.  

Statistical Analysis  
A mixed-models analysis of variance was performed for each of the dependent variables 
(VAS, US, elastography, and PPT). The covariates considered in the analysis were the 
participants’ sex, side of treatment, height, weight, and age. A step-wise regression was used to 
determine significant covariates for each of the dependent variables. Following the step-wise 
regression the primary variables of interest, treatment and time of measurement were added 
along with their interaction for each of the dependent variables. Post hoc t-tests were used to 
evaluate differences in the measurements. All analyses were performed using SAS, version 9.4 
(Chapel Hill, North Carolina) and alpha was set at p<0.05.  
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