Combining Patient Education With Dry Needling and Ischemic Compression for Treating Myofascial Trigger Points in Office Workers With Neck Pain: A Single-Blinded, Randomized Trial

Abstract

Objective

The purpose of this study was to compare immediate and short-term effects of combining dray needling (DN) + patient education vs ischemic compression (IC) + patient education for treating myofascial trigger points (MTP) in office workers with neck pain.

Methods

This was a single-blinded, randomized trial. Thirty-two participants were randomly assigned to either DN + patient education or IC + patient education group. Both groups received 2 treatment sessions with a 48-hour time interval. Pain intensity, cervical range of motion, Neck Disability Index, and satisfaction were measured.

Results

Pain intensity and neck disability level decreased, whereas the cervical range of motion (side-bending and rotation) increased in both groups. Analysis of variance revealed a significant interaction of group × treatment only for pain intensity, indicating a greater reduction in the IC group. Satisfaction generally increased in the follow-up assessment in both groups.

Conclusion

Both intervention groups had some positive immediate and short-term effects after 2 treatment sessions. However, IC + patient education was more effective than DN + patient education in the treatment of MTPs in office workers with neck pain.

Introduction

Work-related neck and shoulder pain is increasing, and it is a common problem, especially in women.¹ Office workers may suffer frequent severe tenderness in the levator scapulae, neck extensors, upper trapezius, and infraspinatus muscles.^2,3 These muscles may be the origin of referral pain to head and neck in people with work-related neck and shoulder pain.⁴ Static postures or repetitive low-level tasks can lead to the development of myofascial pain syndrome.⁵ Myofascial pain syndrome can also be diagnosed by the presence of myofascial trigger points (MTPs). Myofascial trigger points are usually characterized by the presence of a spot or a palpable taut band within skeletal muscles,⁶ and they negatively affect surrounding soft tissues by local inflammation.⁷ In addition to referred pain, muscle weakness and restricted range of motion (ROM) are other symptoms of MTP.

There are a variety of soft tissue techniques for treating myofascial pain, such as massage, stretching, ischemic compression (IC), and dry needling (DN). Ischemic compression and DN are more common techniques, which are based on inactivating MTPs.^8,9 However, a single treatment is not often effective in the clinical pattern of patients owing to multiple factors of MTPs.¹⁰ Furthermore, patients with neck pain may have several disorders, and their symptoms do not automatically respond to a single treatment. Therefore, a multimodal approach has been suggested for the treatment of individuals who suffer from MTPs.¹⁰ On the other hand, the development of prevention strategies should be considered owing to the possibility that excessive computer work and static position of the neck and head can contribute to the start and perpetuation of neck pain.¹¹ Hence, patient education, in addition to other treatments, should be regarded as essential an element of health care.¹² Patient education may enhance the effect of conventional treatment for MTPs of the neck muscles in the office-worker population. Education and advice are usually given in the treatment of neck pain. The typical educational methods are advice, neck school, or education concurrent with other treatments.¹³ Advice usually includes lifestyle modifications with an emphasis on posture, specific exercises, self-care strategies, and workplace ergonomics.

Dry needling has been recommended for treating MTPs for short- and medium-term periods by previous systematic reviews.^3,8,14 Still, IC is the most common and noninvasive therapy currently employed for the treatment of MTPs.³ Applying IC may result in the normalization of biomechanical muscle fiber properties and returning the normal functional condition of muscle.¹⁵ The local therapeutic effects of IC also comprise the stimulation of mechanoreceptors and the reduction of pain signals owing to the depletion of neurotransmitters and temporary block of the local blood flow.¹⁶ Accordingly, IC for treating MTPs induces normalization of the biomechanical properties of the local muscle fibers and quick pain relief, which can restore the normal functional condition of the muscle with reduced risk of injury and better RoM.¹⁷

Some studies have reported the effectiveness of DN and manual therapy on improvement in functionality,¹⁸ increased ROM, and reduced pain perception threshold¹⁹ in patients with neck and shoulder pain.²⁰ One study conducted to investigate the effects of DN concluded that passive stretch and deep DN seems to be more effective than passive stretch only in the management of MTPs in the neck region.¹¹ Another study conducted by Dominik Irnich et al revealed that acupuncture is better than sham in improving ROM and motion-related pain after 1 session of treatment in chronic neck pain patients, and acupuncture improves ROM more than DN.²¹

Corrective movements are currently considered part of a noninvasive, inexpensive, low-risk, and very pleasant solution to reduce pain caused by trigger points (TPs) (Kumar et al).²² It is also necessary to preserve physical function for performing self-care activities in persons with chronic conditions, for example, pain with TP origin. An increased sense of confidence plus reduced severity of pain and fatigue can be achieved by regular exercise and improving physical strength.²³

However, to the best of our knowledge, there is a lack of evidence about the effects of patient education combined with other treatments like DN or IC on clinical symptoms (eg, neck pain, neck ROM, and Neck Disability Index [NDI]) in office workers. Therefore, the present study aimed to compare the immediate and short-term effects of combining DN + patient education vs IC + patient education for treating MTPs in office workers with neck pain. It was hypothesized that office workers receiving IC + patient education would show greater improvements in satisfaction, neck ROM, pain, and disability than those receiving DN + patient education.

Methods

Research Design

A single-blinded, randomized trial was performed from June to October 2018. This study was conducted based on the Guidelines for Consolidated Standards of Reporting Trials.

Participants

G*Power 3 was used to calculate the sample size. The sample size of the 20 participants in each group was capable of detecting a 20% difference in the Numeric Pain Rating Scale (NPRS) between the IC and DN groups according to a similar study²⁰ assuming a standard deviation of 10%, a significance level of 0.05, and a power of 80%.

All participants were aged between 25 and 40 years. Female office workers with neck pain related to MTP were recruited from a public physical therapy clinic or a general hospital related to Tehran University of Medical Sciences University of Medical Sciences. Participants were included if they were office workers with at least 3 hours of daily computer work and had mechanical neck pain (for more than 90 days) with an NDI score ≥ 15 and an NPRS score ≥ 3 at rest or during active movement of the cervical spine.

Participants were excluded from the study if they had a history of traumatic injuries, systemic diseases, neurologic diseases, presence of neck pain related to headache (ie, tension headache or migraine), history of surgery in the cervical region, clinical diagnosis of cervical radiculopathy, or myelopathy. The diagnosis was made by an orthopedic surgeon; then, participants underwent clinical examination by an expert physical therapist in musculoskeletal disorders. After applying the criteria mentioned earlier, 35 of 48 participants were included in this study (Fig 1). Participants were randomly allocated to 1 of 2 different intervention groups (DN or IC) using a computer-generated random-sequence table.

Fig 1.

The flow of the participants throughout the study.

The study procedure was clearly explained to all participants, and they signed an informed consent form before participation. This study was approved by the ethical committee at the Tehran University of Medical Sciences University of Medical Sciences and conducted following the Declaration of Helsinki. This study was registered at ClinicalTrials.gov.

Outcome Measures

A blinded examiner carried out the measurements and registered the data. The following outcomes were collected by the examiner or self-report questionnaires.

Numeric Pain Rating Scale

The NPRS is a simple and easy-to-measure scale for assessing pain. It consists of a sequence of numbers, from 0 to 10, where 0 represents “no pain” and 10 represents the “worst pain you can imagine.” In this way, individuals will grade their pain based on this parameter.²⁴ Cleland et al (2008) report a clinically significant minimum difference of 2.1 points for patients with neck pain.²⁵

Cervical ROM

Range of motion was objectively measured by a cervical goniometer. The participants were asked to sit upright with relaxed shoulders and hands resting on thighs and flexed hips and knees at 90°. A reliable procedure in patients with neck pain was used to assess the neck movements.²⁶ For side-bending assessment, participants were instructed to bring the ear toward shoulder as far as possible, maintaining the face to the front and not moving the shoulder; for rotations, participants were instructed to turn the head to the side without moving the shoulders. All movements had to be performed pain free. In some participants, the movement had to be hand guided to reach a proper movement.

Neck Disability Index

Another self-reported outcome was the NDI, which consists of 10 items assessing different functional activities. The overall score (100) is obtained by adding the score for each item and multiplying by 2, and a higher score indicates greater pain and disability. Seven points are the minimum clinically significant difference.²⁷

Satisfaction Assessment

Satisfaction was assessed using a 5-point Likert score: (1) very unsatisfied, (2) unsatisfied, (3) neither unsatisfied nor satisfied, (4) satisfied, and (5) very satisfied. Measurements were completed before the first treatment session (baseline), after 2 treatment sessions, and after 3 weeks of completing the treatments (follow-up).

Procedures and Interventions

After the final assessment, eligible participants were randomly allocated to either the DN group (n = 17) or the IC group (n = 18) using a computer-based program. One participant from the DN group and 2 from the IC group could not attend the follow-up sessions; consequently, 32 participants completed the study with no reported side effects (Fig 1). All participants received 2 treatment sessions with a 48-hour interval in 1 week. Both groups received patient education (ie, postural correction, lifestyle modification, and exercise therapy) in addition to DN or IC. Some important advice was, for example, performing 5 exercises for shoulder and neck, changing position after a half-hour of working, using clips for long and heavy hair, avoiding a long time working or sitting in a poor position, and sleeping in a correct position.

The MTPs were found by index finger while the participant lay in the horizontal recumbent position. Active MTPs were identified by the presence of local pain during palpation and referred pain. The pain was assessed before the first treatment session and after the second treatment session using the NPRS for spontaneous pain. Based on the high prevalence of MTPs in the upper trapezius, levator scapulae, and post-cervical muscles, these muscles were selected for DN or IC intervention.

DN Group

The DN group received 2 treatment sessions for the levator scapulae, upper trapezius, and postcervical muscles on the affected side (plus patient education). The Hong technique was used to perform DN.²⁸ The needles used were 0.26 × 25 mm. A physical therapist started the technique by palpating an active MTP and localizing the more sensitive taut band of that muscle. Then, the needle was inserted in the direction of the taut band, perpendicular to the skin, and was moved to the MTP until a first local twitch response was activated. The local twitch response was a transient and involuntary contraction of the taut band, which was perceived by the therapist. The needle insertion was repeated to complete at least 3 local twitch responses; then, the needle was removed. The needling procedure for each MTP lasted approximately 2 minutes. Firm compression was applied to the insertion site for 40 seconds to avoid excessive bleeding when the needle was removed.

IC Group

This group received the IC technique over the MTPs (plus education). For this technique, the physical therapist applied gradually increasing pressure to the MTP until the participant felt the sensation of pressure changed into pain; then, the pressure was maintained until the discomfort eased; at that moment, the pressure was increased again until discomfort was perceived by the participant. This published procedure was repeated for 90 seconds while the participant was lying prone.^29,30

Statistical Analysis

SPSS software package was used to analyze the data. The data were tested for normality with the Shapiro-Wilk test, histograms, and residual plots for visual inspection. Normal distribution was confirmed for the NDI, NPRS, ROM of neck side flexion, and rotation. Repeated-measures analysis of variance (ANOVA) was used on NDI, NPRS, ROM of side flexion, and ROM of neck rotation to determine whether significant differences existed between the groups. Pairwise comparisons with Bonferroni correction were performed to identify significant differences between the groups. A chi-square test was used to find significant satisfaction differences between the groups. The significance level was set at P < .05.

Results

Figure 1 demonstrates the flow of recruitment throughout the study. The mean number of received treatment was 2 for the DN group and 2 for the IC group. Seventeen participants in the DN group and 18 participants in the IC group received treatment. However, there were 3 dropouts, 1 patient in the DN group and 2 patients in the IC group in the follow-up assessment. Table 1 shows the baseline demographics and descriptive statistics for the outcome variables in each group. No significant differences between the groups were detected for any of the analyzed variables.

Table 1.

Demographic and Clinical Characteristics Before the First Session and After the Second Session of Each Group (n = 16)

			NDI(points)		NPRS(points)		Side Flex(°)		Rotation(°)
	Age(y)	BMI (kg/m2)	Baseline	Session 2	Baseline	Session 2	Baseline	Session 2	Baseline	Session2
DN	38 ± 14.4 (36.2-40.1)	22 ± 1.7 (21.5-23.3)	25 ± 5.8 (23.7-27.4)	11.3 ± 7.6 (9.1-13.7)	7.5 ± 1.4 (5.4-9.9)	4.1 ± 2.2 (2.1-6.3)	35 ± 11.1 (32-37.6)	51.4 ± 13.4 (49.3-53.8)	47.7 ± 7.4 (45.8-49.4)	65 ± 7.8 (63-67)
IC	39 ± 13.9 (37.5-41.2)	22.4 ± 1.9 (21.4-23.6)	25.2 ± 5.9 (23.8-27.6)	6.8 ± 5.6 (4.3-8.8)	7.35 ± 1.3 (5.3-9.9)	2.2 ± 1.7 (1.2-4.4)	34.1 ± 7.7 (32.2-36.7)	44.5 ± 5.5 (42.4-46.7)	47 ± 8.4 (45.4-49.3)	66.3 ± 8.7 (64.3-68.4)

BMI, body mass index; DN, Dry needing; IC, ischemic compression; NDI, Neck Disability Index; NPRS, Numeric Pain Rating Scale.

Data are presented as mean ± standard deviation (95% confidence interval).

Between-Group Analysis

Repeated-measures ANOVA revealed a significant main effect of treatment on NPRS (F = 152.24, P < .001, 95% CI = 3.6-5), NDI (F = 95.89, P < .001, 95% CI = 12.5-19.1), ROM of rotation (F = 63.08, P < .001, 95% CI = 14.1-24.2), and ROM of side flex (F = 20.7, P < .001, 95% CI = 6.1-19.3).

There were no significant effects of group on NPRS (F = 3.2, P = .08), NDI (F = 1.24, P = .24), ROM of rotation (F = 0.003, P = 1), and ROM of side flex (F = 1.76, P = .2).

There was only 1 significant interaction of treatment × group on NPRS (F = 6.2, P = .02, 95% CI = 2.3-3.9). However, there was no significant interaction of treatment × group on NDI (F = 2.81, P = .1), ROM of rotation (F = 0.22, P = .6), or on ROM of side flex (F = 2.13, P = .2).

Within-Group Analysis

One-way repeated-measures ANOVA showed significant effects of DN treatment on NPRS (F = 37.7, P < .001, EF = 0.77, 95% CI = 2.2-4.6) and effect of IC treatment on NPRS (F = 142.8, P < .001, EF = 0.92, 95% CI = 4.2-6.1). It showed a significant effect of DN treatment on NDI (F = 24.5, P = .001, EF = 0.71, 95% CI = 7.2-19) and effect of IC demonstrated (F = 88.5, P < .001, EF = 0.87, 95% CI = 14.3-22.7). The analyses also revealed a significant effect of DN treatment on ROM of rotation (F = 27.6, P < .001, EF = 0.73, 95% CI = 10.4-25.6) and effect of IC on ROM of rotation (F = 35.8, P < .001, EF = 0.79, 95% CI = 12.7-27.8). However, there was no significant effect of DN treatment on ROM of side flex (F = 13.7, P = .005, EF = 0.60, 95% CI = 6.8-28.2) and effect of IC demonstrated (F = 7.01, P = .03, EF = 0.44, 95% CI = 1.3-16.7).

Satisfaction

As can be seen in Table 2, satisfaction generally increased in the follow-up assessment in both groups; satisfaction of patients improved in the DN group (9 patients = 56.25% satisfied, and 7 = 43.75% very satisfied), and IC group (1 patient = 6.25% satisfied, and 15 = 93.75% very satisfied). However, analysis with the chi-square test did not show any significant difference between the 2 groups (P = .12).

Table 2.

Satisfaction Assessment After the Second Treatment Session and 3-Week Follow-up

Group		Very Unsatisfied	Unsatisfied	Neither Satisfied nor Unsatisfied	Satisfied	Very Satisfied
DN (n = 16)	Session 2	0	1	4	6	5
	Follow-up	0	0	0	9	7
IC (n = 16)	Session 2	0	0	1	6	9
	Follow-up	0	0	0	1	15

DN, dry needing; IC, ischemic compression.

Discussion

This study investigated the immediate and short-term effects of combined DN + patient education vs IC + patient education for treating MTPs in office workers with neck pain. We found that reactive hyperemia after the application of IC may lead to a better oxygen supply and less production of nociceptive and inflammatory substances, resulting in more satisfaction contrary to discomfort that resulted after DN. This study showed that 2 treatment sessions of MTPs with DN or IC leads to significant improvement in the outcome measures. Adding patient education about postural correction, ergonomic modification, and some self-exercises resulted in an increase in satisfaction at 3 weeks follow-up. The acceptable effect size of IC and DN for pain, disability, and ROM were positive after 2 days and higher in the IC group. A multimodal approach has been recommended to be investigated in patients with excessive computer work neck pain.¹⁰ The static position of the neck and head can contribute to the start and perpetuation of neck pain; also, poor postural habits are contributing to the persistence of MTP pain and lack of treatment success.

In line with our findings, 2 studies observed a similar decrease in the pain intensity assessed by the NPRS after both interventions.^18,20 In contrast to the findings of Ziaeifar et al, we found a significantly higher decrease in the pain with IC compared with DN.³¹ Also, a few studies investigated the effect of combining treatment with DN or IC.32, 33, 34 Nagrale et al (2010) found better improvement in pain intensity after a combination of IC techniques, compared with muscle energy technique alone.³⁵ Little is known about the mechanisms underlying the effects of DN and IC on pain, but several hypotheses have been suggested. Needle stimulation of the MTP may lead to increased blood flow and a reduction in nociceptive substances.36, 37, 38 Dry needling may also stimulate Aδ fibers and activate inhibitory pain systems.³⁹ Also, pain relief from trigger-point compression may result from reactive hyperemia and a spinal reflex mechanism, resulting in a release of muscle spasm.⁴⁰

In contrast to De Meulemeester (2017),²⁰ our study indicated that the decrease in NPRS was more than the minimal detectable patient-perceived change > 1.5 points. Published paradoxical results may relate to different participants or setting, or lower baseline scores in the previous studies. Based on Cagnie's study, there was moderate evidence for IC and strong evidence for DN to have a positive effect on pain intensity.³ Moreover, Campa-Moran and colleagues (2015) concluded that IC was more effective than DN in the reduction of pain intensity (68.3% and 39.3%, respectively).³²

Previous studies also indicated a decrease in the NDI score with DN^20,41 and IC.³⁵ In contrast, Cagnie et al (2013) found no significant changes in the NDI score.³⁶ In the present study, the observed changes were higher than the minimal clinically significant difference for NDI, which requires a decrease of 14 points to obtain a patient-perceived change. The improved functionality may occur because of a decrease in the pain and improvement of muscle tone. Our results were the opposite of Campa-Moran (2015) results that IC was not effective the same as the DN group on NDI.³²

Simons et al (1999) hypothesized that TPs could induce restricted ROM in the tissues.⁴ In the present study, ROM improved significantly in both groups after the treatment, which is also in agreement with the previous studies after DN treatment.⁴² Lengthening of the sarcomeres, a decrease of abnormal tension of the taut band, and general pain reduction may be the cause of increasing ROM. Based on Cagnie's study (2015), there was a similar moderate effect of 2 treatments on mobility. A few studies have observed an increase in ROM after single or several sessions of IC.^35,43 For example, Cagnie et al (2013) reported that the patients treated with IC resulted in a significant improvement in flexion, extension, and side bending.³⁶

In comparing 2 kinds of treatments, only 1 significant difference was seen in NRPS with a better result in the IC group, but not in the disability or mobility scores.

Our results were comparable to the published findings in the effect size of some parameters.^3,32 The effect size of the IC on the change in pain, NDI, and ROM were larger than DN after 2 sessions of treatment. It might be due to the muscle soreness in the DN group. Usually, applying DN might provoke a short contraction of muscle fibers; therefore, it causes a typical soreness in the treated region for some hours. The GRADE approach⁴⁴ explains that DN is a passive modality, and it may help in reducing musculoskeletal pain, allowing for additional physical therapy interventions to maximize functional outcomes and reduce patient disability.⁴⁵

Some studies used patient education in the treatment of patients with neck pain, but there is low-quality evidence about the effect of patient education on the reduction of pain and disability.⁴⁶ Eliminating any perpetuating factors, introducing adequate education and lifestyle modification, and changing work-related positions and home programs for patients are some essential factors to perpetuate the positive effects of these treatments.^4,26

Patient-centered care is one of the key goals of rehabilitation,⁴⁷ and patient satisfaction is a multidimensional concept, which is affected by cultural, social, cognitive, and emotional factors.⁴⁸ Patient satisfaction is a mental perception, and a comparison of health care quality with the patient's mental standards, which is usually assessed by subjective methods.⁴⁹ It is widespread to use a questionnaire in many studies to assess patients’ satisfaction because of easy management, cost-effectiveness, and reproducibility.⁵⁰ Still, it seems that no study investigated the satisfaction of patients after DN or IC treatment. Our results revealed generally increased satisfaction after a 3-week follow-up because the participants learned and practiced postural correction, lifestyle modification, and some self-exercises for 3 weeks. After 2 sessions of treatment, participants in the DN group were mostly satisfied (37.5%) or very satisfied (31.25%), whereas more were very satisfied (56.25%) in the IC group. It seems that the number of very satisfied persons was higher in the IC group. Furthermore, in follow-up assessment, the satisfaction of the participants increased in the DN and IC groups. However, the analysis did not reveal any significant difference between the DN and IC groups. It may be possible that with increasing sample size, the results reveal a significant difference in favor of the IC group.

The upper trapezius is often clinically indicated as the muscle of interest in office workers. However, other muscles of the neck and shoulder complex, such as the levator scapula, neck extensors, and infraspinatus muscles, demonstrated a high prevalence of severe tenderness in this population. Thus, attention and treatment to other muscles should be emphasized.²

Dry needling stimulates the A-delta nerve fibers, which in turn may activate the enkephalinergic inhibitory dorsal horn interneurons.⁵¹ Several studies have demonstrated changes in the chemical properties of MTPs combined with eliciting local twitch responses following DN. It is suggested that DN normalizes the chemical properties of the MTP site in the muscle. Local twitch responses have been thought to reduce the concentration of sensitizing substances in the MTP and are considered as an essential parameter in breaking the centrally mediated vicious cycle of the MTP phenomena.²⁰

Our data also revealed significant differences in the NDI and ROM measures after 2 sessions of IC. Immediate and short-term effects of IC on pain intensity have been reported, which is attributed to the effect of IC on reactive hyperemia in the TP region, counterirritant effects, or a spinal reflex mechanism for the relief of muscle spasm.³⁶

The main goal of DN and IC is mainly rapid pain relief in clinical practice. Former studies have mainly evaluated the immediate effect of 2 treatment sessions; however, to our best knowledge, this study is the only study directly investigated the effect of adding patient education for postural correction, lifestyle modification, and self-exercises to the immediate effect of DN and IC on MTPs after 3 weeks. The lack of differences between the DN and MP groups may be explained by the fact that all treated muscles are superficial muscles, so they are all easily accessible for both techniques. This could be interesting for clinical practice, as IC could serve as a useful alternative for the treatment of myofascial pain, in case of needle phobia of a patient or limited DN skill of a therapist. Future randomized control trials with long-term follow-up should investigate the benefit of patient education and self-exercises in patients with neck pain.

Limitations

First, the sample of 16 individuals in each group was smaller than the calculated sample size of 20 individuals. Second, participants were only female, and men were not included. Moreover, there was no control or placebo group in our study. Also, the age range was limited to 25 to 40 years old to avoid the aging effect. Therefore, the results cannot be extended to others, such as, older adults who may experience age-related structural changes as well. There was also a short follow-up period; we assessed outcomes from only 2 sessions of treatment.

Conclusion

This study described the potential benefits of combining patient education with the DN or IC technique as a multimodal treatment for MTPs in office workers with neck pain. We found that for those in this study, DN and IC resulted in a similar effect on immediate and short-term follow-up for relieving pain and eliminating the symptoms in individuals with MTPs, with faster positive results using IC.

Funding Sources and Conflicts of Interest

This research was funded by the Tehran University of Medical Sciences (Grant No 32235). The authors declare that they have no competing interests.

Contributorship Information

Concept development (provided idea for the research): K.O.

Design (planned the methods to generate the results): K.O., H.S.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): K.O., H.S.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): K.O.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): S.H.J., K.O.

Literature search (performed the literature search): K.O., O.R.

Writing (responsible for writing a substantive part of the manuscript): O.R., K.O.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): K.O., H.S., S.H.J., O.R.

Practical Applications.

• •A multimodal approach showed some positive immediate, and short-term effects for the treatment of myofascial trigger points.
• •Ischemic compression +patient education may be a promising treatment in myofascial trigger points.
• •Ischemic compression and DN modality both had positive results for acute on neck pain and disability indices in treating myofascial trigger point in office workers

Alt-text: Unlabelled box