Despite a paucity of experimental evidence, clinical opinion remains that though LTrPs allow pain-free movement, they are primarily associated with deleterious motor effects and occur commonly in 'healthy' muscles. The primary aim of this study was to investigate the effects of LTrPs on the muscle activation patterns (MAPs) of key shoulder girdle muscles during scapular plane elevation of the arm in the unloaded, loaded and fatigued states. In connection with the main aim, a preliminary study was carried out to examine the frequency with which LTrPs occur in the scapular positioning muscles in a group of normal subjects. After establishing intra-examiner reliability for the clinical examination process, 154 healthy subjects volunteered to be screened for normal shoulder girdle function, then undergo a physical examination for LTrPs in the trapezius, rhomboids, levator scapulae, serratus anterior and the pectoralis minor muscles bilaterally. Of these 'healthy' subjects, 89.8% had at least one LTrP in the scapular positioning muscles (mean=10.65 ± 6.8, range=1-27), with serratus anterior and upper trapezius harbouring the most LTrPs on average (2.46 ± 1.8 and 2.36 ± 1.3 respectively). Consistent with clinical opinion, this study found that LTrPs occur commonly in the scapular positioning muscles. To investigate the motor effects of LTrPs, surface electromyography (sEMG) was used to measure the timing of muscle activation of the upper and lower trapezius and serratus anterior (upward scapular rotators), the infraspinatus (rotator cuff) and middle deltoid (arm abductor). These studies found that LTrPs housed in the scapular upward rotator muscles affected the timing of activation and increased the variability of the activation times of this muscle group and were also associated with altered timing of activation in the functionally related but LTrP-free infraspinatus and middle deltoid. Compared with the control group (all muscles LTrP-free), the MAPs of the LTrP group appeared to be sub-optimal, particularly in relation to preserving the subacromial space and the loading of the rotator cuff muscles. After the initial sEMG evaluations, the LTrP subjects were randomly assigned to one of two interventions: superficial dry needling (SDN) followed by post-isometric relaxation (PIR) stretching to remove LTrP s or sham ultrasound, to act as a placebo treatment where LTrPs remained. Where LTrPs were removed, a subsequent sEMG evaluation found MAPs to be similar to the control group in most of the experimental conditions investigated. Of particular note, when LTrPs had been treated and the subjects repeated the fatiguing protocol, the resultant MAP showed no significant difference with that of the control group in the rested state, suggesting treating LTrPs was associated with an improved response to fatigue induced by repetitive overhead movements. In conclusion, the findings indicate that LTrPs commonly occur in scapular positioning muscles and have deleterious effects on MAPs employed to perform scapular plane elevation and thus affect motor control mechanisms. Treating LTrPs with SDN and PIR stretching increases pressure-pain thresholds, removes associated taut bands and at least transiently optimises the MAP during scapular plane elevation. Discussion includes possible neuromuscular pathophysiology that might explain these results.

M.Tech. / Purpose: A study to determine the efficacy of Traumeel® gel using phonophoresis in the treatment of a latent trapezius myofascial trigger point, with regards to pain perception, cervical spine range of motion and pressure pain tolerance.Methods: A single-blinded, controlled study design was utilised. Thirty participants who all presented with a latent trapezius myofascial trigger point were randomly divided into two groups of fifteen. Each individual was subjectively and objectively assessed from baseline values prior to receiving treatment. Group A received ultrasound utilising ultrasound gel over the trapezius myofascial trigger point, as the control group. Group B received phonophoresis with Traumeel® gel over the trapezius myofascial trigger point. All participants received two treatments per week, with a total of seven consultations, over the three week study period. The subjective data was obtained utilising a Numerical Pain Rating Scale (NPRS) whilst a hand held Algometer tested pressure pain tolerance and a Cervical Range of Motion Measuring Instrument (CROM) measured cervical spine range of motion. These were utilised to form the objective data. The Data was analysed using non-parametric tests. The two independent treatment groups were assessed for capability at treatments one, four and seven using the Mann-Whitney U-test (non-parametric version of the independent sample T-test). Changes over the three week period were observed and analyzed using the Repeated Measures test or the Friedman Test (Devey, 2010). Results: In this study ultrasound utilising ultrasound gel had a statistically significant impact on the trapezius myofascial trigger point. Statistical analysis of the Traumeel® gel suggests that there was no statistical significance with regards to any of the treatment parameters or variables measured. Subjectively ultrasound gel proved to be statistically and clinically significant in decreasing the participant’s pain perception. There was no statistical improvement but there was a clinical improvement in the Traumeel® gel group.

Background: Biomechanical stiffness has been linked to risk of injury and found to be a measureable characteristic in musculoskeletal disorders. Specific identification of stiffness may clarify who is most likely to benefit from the trigger point dry needling (TDN). The purpose of this study is to investigate the reliability and concurrent validity of the MyotonPRO® to the criterion of shear wave ultrasound elastography for the measurement of biomechanical stiffness in the infraspinatus, erector spinae, and gastrocnemius of healthy subjects over increasing muscle contraction. Second purpose is to investigate the biomechanical effects of TDN to latent myofascial trigger points (MTrPs) in the infraspinatus, erector spinae, or gastrocnemius. Research Design and Method: The first phase of the study investigated 30 subjects who completed three levels of muscle contraction in standardized test positions for the infraspinatus, erector spinae and gastrocnemius. Biomechanical stiffness measures were collected using shear wave elastography and MyotonPRO®. The second phase of the study investigated 60 new subjects who were categorized into infraspinatus, erector spinae, or gastrocnemius group based on an identified latent MTrP. These subjects underwent TDN while monitoring biomechanical stiffness at baseline, immediately post TDN, and 24 hours later. Analysis: Discriminate ability, reliability, and correlations were calculated for measured stiffness variable across the three conditions of contraction in the first phase of the study. Differences between stiffness at baseline and after TDN were calculated in the second phase of the study. Results: Correlation of the two measurement methods in the three muscle regions was significant and strongest in the gastrocnemius. MyotonPRO reliability was excellent, and demonstrated ability to discriminate between the three levels of muscle contraction. In the second phase, immediate decreased stiffness was observed in the MTrP following TDN treatment. Significant decreased stiffness was found in in the erector spinae and gastrocnemius group who also demonstrated a localized twitch response during TDN. Stiffness returned to near baseline values after 24 hours. Discussion: The MyotonPRO® stiffness measurement was found to be reliable and discriminate across predefined muscle contraction intensities. TDN may cause an immediate change in stiffness but this change was not observed at 24 hours. It is not known whether these effects are present in a symptomatic population or related to improvements in other clinical outcomes. Future studies are necessary to determine if a decrease in biomechanical stiffness is an indication of patient improvement in pain and function.

Les PTM sont une source de douleur régionale et de dysfonctionnements neuromusculaires. Ils sont couramment associés à une hyperalgésie, à des troubles comportementaux et des restrictionsfonctionnelles. La douleur est bien documentée dans la littérature scientifique mais les études de ses conséquences sur le mouvement reposent exclusivement sur l’analyse de gestes simples. L’objectif dece travail est d’étudier la douleur myofasciale du membre supérieur et de vérifier si une technique de thérapie manuelle influençant cette douleur permet de rétablir la performance motrice d’un mouvement fonctionnel. Quatre études ont été réalisées afin d’analyser : 1) la performance motrice d’un mouvement elliptique dans le plan horizontal ; 2) dans le plan frontal et d’une tâche de tapement ; 3) la douleur sur le membre supérieur non atteint chez des sujets ayant subi un AVC ; 4) l’incidence de la douleur chez le personnel soignant d’un centre hospitalier. Les résultats indiquent que la présence de PTM produit la douleur myofasciale et : 1) n’influence pas significativement la performance motrice d’un mouvement elliptique horizontal ; 2) altère la performance motrice d’un mouvement elliptique frontal et d’une tâche de tapement chez les sujets présentant des PTM ; 3) modifie aussi la fonction motrice de l’extrémité supérieure ipsilatérale à la lésion ; 4) touche 8,43% du personnel soignant, étant bilatérale et pouvant conduire à des arrêts maladie dans 14,28 % des cas. L’application d’une technique de compression ischémique locale permet de retrouver la quasi-totalité de la fonction motrice. Il semblerait qu’une reprogrammation du mouvement s’avère nécessaire pour récupérer totalement la fonction motrice. / Myofascial Trigger Points (MTrPs) are source of regional pain and neuromuscular dysfunctions. They are associated to hyperalgesia, psychological disturbances and functional restrictions. Despite myofascial pain has been extensively studied, researches about its influence have only analyzed uniarticular motions. The mains goals of this research were to study the upper limb myofascial pain and to verify whether the application of manual therapy, influencing this pain, could contribute to the motor performance recovery of multiarticular motion. Four studies were carried out in order to analyze: 1) motor performance of an elliptic motion in the horizontal plane, 2) motor performance of an elliptic motion in the frontal plane including an analysis of a tapping task, 3) non-paretic upper limb pain of the stroke patients, 4) myofascial pain incidence at the medical staff in a hospital. The results showed that the presence of TrPs produces myofascial pain. This pain: 1) does not influence significantly the horizontal elliptical motions motor performance, 2) deteriorates the frontal elliptical motions motor performance and the execution of the tapping task, 3) modifies the non-paretic upper limb motor function of the stroke patients, and 4) 8,43 % of medical staff suffers from bilateral myofascial pain, leading to absence at workplace in 14,28% of the cases. The application of local ischemic compression technique allows high recovery of the upper limb motor function. Motor reprogramming therapies could contribute to recover the motor function completely.

Tyrimo tikslas: Įvertinti moterų griaučių raumenų sistemos viršutinės dalies funkcinę būklę prieš ir po pasyvios ir aktyvios kineziterapijos priemonių taikymo. Tyrimo uždaviniai: 1. Įvertinti moterų griaučių raumenų sistemos viršutinės dalies raumenų skausmo slenksčio pokyčius prieš ir po pasyvios ir aktyvios kineziterapijos. 2. Nustatyti moterų griaučių raumenų sistemos viršutinės dalies judesių amplitudės pokyčius prieš ir po pasyvios ir aktyvios kineziterapijos priemonių taikymo. 3. Įvertinti moterų griaučių raumenų sistemos viršutinės dalies raumenų jėgos pokyčius prieš ir po pasyvios ir aktyvios kineziterapijos. 4. Palyginti pasyvios ir aktyvios kineziterapijos priemonių efektyvumą moterų griaučių raumenų sistemos viršutinės dalies raumenų skausmo slenksčiui, judesių amplitudei bei raumenų jėgai. Tyrimo metodai: Buvo ištirtos 20 jauno ir vidutinio amžiaus sveikos moterys. Tiriamosios buvo suskirstytos į dvi grupes. Vienai grupei buvo taikomos pasyvios kineziterapijos priemonės, kitai – aktyvios. Prieš ir po kineziterapijos buvo vertinamas spaudimo sukeltas raumenų skausmo slenkstis (algometru), žasto judesių amplitudė (goniometru), rankų sukabinimo už nugaros ir kaklo judesių amplitudė (centimetrine juostele), pečių juostos raumenų jėga (rankos dinamometru ir „Stabilizer Pressure Biofeedback“ prietaisu). Išvados: 1. Po pasyvios kineziterapijos priemonių taikymo raumenų skausmo slenkstis statistiškai reikšmingai padidėjo 20- yje iš 22- jų vertintų miofascijinių... [toliau žr. visą tekstą] / The aim of the research: To evaluate women’s upper part of musculoskeletal system functional state before and after passive and active physical therapy. To achieve this aim the following tasks were set up: 1. To evaluate changes of muscle pain threshold in the upper part of the musculoskeletal system. 2. To assess changes of range of motion in the upper part of the musculoskeletal system. 3. To evaluate changes of muscle force in the upper part of the musculoskeletal system. 4. To compare the effect of passive and active physical therapy for the muscle pain threshold, range of motion and muscle force in the upper part of the musculoskeletal system. Method of the research: 20 young and middle-aged healthy women were tested. Subjects were divided in to two groups. We have applied passive physical therapy modalities for the first group, active physical exercises for the second group. We have assessed the muscle pain threshold (using algometer), the range of motion (goniometer and tape – measure) and muscle force (hand held dynamometer and „Stabilizer Pressure Bioffedback“) before and after passive and active physical therapy. Conclusions: 1. After the passive physical therapy the muscle pain threshold statistically significant increase in the 20 of 22 assessed myofascial trigger points (p<0,05). After active physical therapy - the muscle pain threshold a statistically significant increase in 12 of 22 assessed myofascial trigger points (p<0,05). 2. After passive physical... [to full text]

Tyrimo problema: miofascijinis skausmo sindromas, sukeltas aktyvių miofascijinių trigerinių, taškų vargina lėtiniais raumenų skausmais, sutrikdo judesių amplitudę, miegą ir gyvenimo kokybę. Latentiniai miofascijiniai trigeriniai taškai bet kuriuo metu, paveikti bet kokio mechaninio stimulo gali tapti aktyviais. Gydant ir taip šalinant latentinius miofascijinius trigerinius taškus užkertamas kelias aktyvių miofascijinių trigerinių taškų formavimuisi ir tuo pačiu miofascijinio skausmo sindromo atsiradimui. Tyrimo objektas: kaklo judesių amplitudės ir miofascijinių trigerinių taškų sukelto skausmo pokyčiai taikant miofascijinių trigerinių taškų terapiją ir tempimo pratimus. Tyrimo tikslas: nustatyti miofascijinių trigerinių taškų terapijos ir tempimo pratimų poveikį skausmui ir kaklo judesių amplitudei. Tyrimo uždaviniai: 1. Nustatyti išeminės kompresijos poveikį galvos sukamojo ir trapecinio viršutinės dalies raumenų miofascijinių trigerinių taškų sukeltam skausmui ir kaklo judesių amplitudei. 2. Nustatyti išeminės kompresijos ir tempimo pratimų poveikį galvos sukamojo ir trapecinio viršutinės dalies raumenų miofascijinių trigerinių taškų sukeltam skausmui ir kaklo judesių amplitudei. 3. Palyginti išeminės kompresijos taikomos atskirai ir kartu su tempimo pratimais veiksmingumą mažinant galvos sukamojo ir trapecinio viršutinės dalies raumenų miofascijinių trigerinių taškų sukeltą skausmą ir didinant kaklo judesių amplitudę. 4. Nustatyti miofascijinių trigerinių taškų sukelto... [toliau žr. visą tekstą] / Problem of study: Myofascial pain syndrome, caused by active myofascial trigger points, causes chronic muscle pain, restricts range of motion, decreases sleep and quality of life. Latent myofascial trigger points at any time can transforme into active myofascial trigger points, when a mechanical stimulus appears. Treating and eliminating latent myofascial trigger points prevent latent myofascial trigger points from transforming into active myofascial trigger points, and hence, prevent the development of myofascial pain syndrome. Object of study: changes of cervical range of motion and myofascial trigger points pain after application of myofascial trigger point therapy and streching exercises. Aim of study: to determine the impact of myofascial trigger point therapy and streching exercises for MTrPs pain and cervical range of motion. Goals of study: 1. To determine the change of sternocleidomastoid and upper trapezius muscles myofascial trigger points pain and cervical range of motion, when ischemic compression is applied. 2. To determine the change of sternocleidomastoid and upper trapezius muscles myofascial trigger points pain and cervical range of motion, when ischemic compression and streching exercises are applied. 3. To compare the effectiveness of ischemic compression and streching exercises on sternocleidomastoid and upper trapezius muscles myofascial trigger points pain and cervical range of motion. 4. To determine the relation beatween myofascial trigger points pain... [to full text]

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2018. / BACKGROUND: Temporomandibular disorders (TMDs) affect up to fifteen percent of adults. It produces craniofacial pain of musculoskeletal structures within the head and neck. One particular cause of TMDs is said to be myofascial pain syndrome (MFPS), which according to various research papers, if not considered and/or assessed, the general cause of a patient’s pain could be disregarded and incorrect treatment offered. Numerous studies conducted internationally on dental management of temporomandibular joint disorder (TMJD) concluded that there is a significant gap in dentists’ education and training regarding the identification and management of MFPS. Upon reviewing the current literature available in South Africa, very little research existed on dentists’ knowledge and the management strategies that they utilised regarding MFPS in TMJD patients. OBJECTIVES: To determine the dentists’ knowledge regarding MFPS of the temporomandibular joint (TMJ). What assessment and treatment/management strategies they use, and whether they make use of referral networks and if the respondents’ demographics influence their knowledge, utilisation, perception and referral patterns. METHODOLOGY: The researcher developed a research questionnaire, which was validated by both an expert and a pilot study group. This questionnaire was then used as a research tool in this cross-sectional study. General dental practitioners from the Greater eThekwini Region received an invitation to participate. The questionnaire-based survey consisted of five sections: biographical profile of respondents; topic background; perception; knowledge; utilisation and management (including referral patterns) of MFPS. RESULTS: The majority of respondents did receive basic education in MFPS, with 76.9% reporting that they received undergraduate education and 57.7% indicating that they had attended post-graduate courses/talks on MFPS. There was a 100% response from dentists indicating their willingness to attend post-graduate courses/talks on MFPS. The results indicated that the respondents, who felt that their curriculum regarding MFPS was sufficient, were more knowledgeable and more competent in diagnosing and managing MFPS. Overall, the average score for knowledge was 65.17%. Clinical features (78.85%) and the perpetuating and relieving factors (72.11%) scored the highest while causes (58.06%) and differential diagnoses (51.16%) scored the lowest knowledge levels. Respondents mostly made use of allopathic medical fields, and not of alternative medical fields, however a high number of respondents (73.1%) indicated that they would consider chiropractic co–management of patients with MFPS. CONCLUSION: This study adds new information in the South African context regarding dentists’ understanding of the myofascial component of TMDs. It also provides the dental profession with information about the knowledge and practices related to MFPS as well as information regarding the strengths and weaknesses on its educational component. It is recommended that dentists receive additional training on differential diagnoses and causes. It is also recommended that the chiropractic profession take this opportunity to offer courses/talks on MFPS and join forces with the dentistry profession on how they can assist in managing patients with MFPS. / M

Abstract Aim: The aim of this study was to investigate if treatment with “dry needling” in myofascial triggerpoints (MTrPs) in the rotatorcuff muscles may affect impingement symptoms such as pain during provocative tests, shoulder mobility, and function. The research questions were: Does the value of pain change on the Visual Analog Pain Scale (VAS) between before and after treatment? Do the positive provocative tests for impingement change between before and after treatment? Does the active shoulder mobility change between before and after treatment? Does the self-rated function change between before and after treatment? Method: The study was a prospective randomized intervention study and 19 persons with impingement symptoms (mean ± standard deviation; 58 ± 18 years, and shoulder pain duration 3.9 ± 1.6 months) were randomized into two groups. The groups were tested before, directly after and 3 weeks after treatment. The intervention group was treated twice, with a week in between, with “dry needling” in MTrPs. The control group was also treated on two occasions but was instead given a superficial needle in the infraspinatus muscle. All subjects were treated by the same physiotherapist. Pain was evaluated on the VAS when subjects performed active shoulder flexion before and after treatment. Provocative tests for shoulder impingement (Neer sign, Hawkins-Kennedy test and Jobe test) as well as range of motion tests were performed before, after and three weeks after treatment. The frequencies of positive/negative provocative tests were presented. Shoulder function was evaluated with the QuickDASH questionnaire. Significance level p≤0.05 was used in the study and a tendency was identified between 0.05 ≤ p &lt; 0.1. Results: There was a tendency (p=0.086) with decreased pain (VAS) in the intervention group after the treatment. Among the impingement tests only significant improved results was observed for Neer sign test three weeks after the treatment (p=0.025) No significant difference could be seen on the active shoulder mobility between before and after the treatment. The perceived function in the intervention group, measured with the Quick DASH questionnaire, showed a tendency (p=0.086) towards a better function. Conclusions: The study showed a tendency towards that”dry needling”  in MTrPs may affect impingement symptoms such as pain and function. The provocative tests for shoulder impingement, Neer sign, showed a significant decrease in pain after treatment. More studies with larger population is needed to make a statement about the effect of “dry needling” in MTrPs as a treatment for shoulder impingement symptoms. / Sammanfattning Syfte och frågeställningar: Syftet med studien var att undersöka om behandling med ”dry needling” (intramuskulär nålstimulering) i myofasciella triggerpunkter (MTrPs) i rotatorcuffmuskulaturen kan påverka impingementsymptom såsom smärta vid provokationstester, axelledsrörlighet och funktion. Frågeställningarna var: Förändras smärtskattning på visuell analog skala(VAS) vid aktiv axelflexion efter jämfört med före behandling? Förändras de positiva provokationstesterna för impingement efter jämfört med före behandling? Förändras den aktiva axelledsrörligheten efter jämfört med före behandling? Förändras den självskattade funktionen efter jämfört med före behandling? Metod: Studien var en prospektiv randomiserad interventionsstudie, 19 forskningspersoner (fp) med impingementsymptom, (medelålder 58 ± 18 år, besvärsdurationens medeltid 3.9 ± 1.6 mån), randomiserades till två grupper. Grupperna undersöktes före, direkt efter och tre veckor efter avslutad behandling. Interventionsgruppen behandlades vid två tillfällen, med en veckas mellanrum, med ”dry needling” i MTrPs medan kontrollgruppen vid två tillfällen istället fick en ytlig akupunkturnål i m infraspinatus. Behandlingen av alla fp utfördes av en och samma fysioterapeut. Smärta utvärderades med (VAS) vid aktiv axelflexion direkt före och efter behandling. Provokationstester (Neer sign, Hawkins-Kennedy test och Jobe test) samt rörlighetsmätning utfördes före, efter och tre veckor efter avslutad behandling. Frekvensen positiva/negativa provokationstesttest summerades. Funktionen utvärderades med frågeformuläret QuickDASH. Signifikansnivå p&lt; 0.05 används i studien och en tendens identifierades mellan 0.05 ≤ p &lt; 0.1. Resultat: Det fanns en tendens (p=0.086) till minskad smärta (VAS) i interventionsgruppen efter jämfört med före behandling. Bland impingementtesterna sågs enbart ett signifikant förbättrat resultat för Neers sign tre veckor efter avslutad behandling jämfört med före behandling (p=0.025). Ingen signifikant skillnad kunde ses gällande rörligheten före och efter behandling. Den upplevda funktionsförmågan mätt med frågeformuläret QuickDASH visade en tendens (p=0.086) mot bättre funktion i interventionsgruppen. Slutsats: Studien har visat tendenser på att ”dry needling” i MTrPs kan påverka impingementsymptom såsom minskad smärta och bättre självskattad funktion efter behandling jämfört med före. Impingementtestet Neer sign visade en signifikant minskad smärta efter behandling. Fler studier med större grupper, större ålderspann och längre behandlingstid behövs för att kunna uttala sig om effekten av ”dry needling” i MTrPs som behandlingsmetod vid impingementsymptom i axeln. / <p>Fristående kurs i Idrottsvetenskap inriktning idrottsmedicin 2013-2015</p>

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2014. / Background: Myofascial Pain and Dysfunction (MPD) is a diagnosis commonly encountered by practitioners, hence, there are several treatment approaches employed by various practicing physicians. Practitioners are required to perform evidence-based protocols on patients; however, such intervention becomes increasingly difficult with the increasing volume of evidence available with regards to treatment of MPD. A systematic review provides a well-structured, critical analysis of the available protocols, and as such, provides practitioners with an evidence-based summary of the available modalities and the effectiveness of these modalities. Thus, the aim of the study was to systematically review and evaluate the literature to determine the effects of various non-invasive modalities on MPD. Objectives: Studies investigating various non-invasive modalities were identified, evaluated against the inclusion criteria and then reviewed against PEDro criteria to present current available evidence regarding their effectiveness as a source of treatment for MPD. Methods: A literature search was conducted, based on key terms including: active and latent myofascial trigger points, manual therapy, manipulation, acupressure, massage, muscle stretching, ultrasound, transcutaneous electric nerve stimulation, electric stimulation therapy, magnetic field therapy, and exercise therapy. Databases searched were: PubMed, EBSCOhost, Medline, CINAL, Proquest, Health Source, Sport Discus, Science Direct, Springer Link, Google Scholar and Summons. The articles were screened according to inclusion and exclusion criteria, after which a secondary hand and reference searches were performed. Thereafter, the articles were reviewed by four independent reviewers and the researcher. The PEDro Scale was used to determine methodological rigor of the included studies. The results were then analysed and ranked. Results: Following the screening process during data collection for this study, a total of 25 studies were identified and included. The review and ranking of these studies revealed a moderate level of evidence present for the effectiveness of Topical Agents. A limited level of evidence was noted for TENS, Ischemic Compression, Ultrasound, Laser and Other Modalities. Approximately 25% of the reviewed studies involved combination therapies; hence their outcomes cannot be applied to the effectiveness of individual modalities. Conclusion: Upon comparison of the quality of evidence available for the various types of modalities present for the treatment of MPD, it was noted that Topical Agents were supported by a stronger level of evidence than TENS, Ischeamic Compression, Ultrasound, Laser and Other Modalities. However, due to a lack of strong overall evidence for any of these modalities it has been concluded that more research is required to establish which modality is in fact the most effective.