influence of instrument assisted soft tissue treatment ......the investigator of this study is a...
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Journal of Bodywork 6t Movement Therapies (2014) 18, 602-607
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Influence of instrument assisted soft tissue treatment techniques on myofascial trigger points Dawn T. Gulick, PhD, PT, ATC, CSCS*
CrossMark
Widener University, One University Place, 126 Cottee Hall, Chester, PA 19013, USA
Received 3 January 2014; received in revised fo rm 12 February 2014; accepted 19 February 2014
KEYWORDS Summary Objective: The purpose of this study was to examine the inf luence of inst rument
IASTT • assisted soft tissue techniques (IASTT) on myofascial tr igger points (MTrP).
MTrP - Design: Randomized, c o n t r o l l e d s tudy w i t h t he researcher assessing the MTrP sens i t i v i ty
Tr igger po i n t pain bl inded to the t r ea tmen t rendered.
Participants: Phase 1 - 27; Phase 2 = 22.
Intervention: MTrPs were ident i f i ed in the upper back. In phase 1, two MTrPs (r ight & l e f t )
were ident i f ied . One was t reated w i t h IASTT, the other was a cont ro l . In phase 2, one MTrP
was i d e n t i f i e d in a t r e a t m e n t and a c o n t r o l g roup. In each phase, t he t r e a t m e n t groups
received six t reatments of IASTT.
Outcome measures: Sensitivity threshold of the MTrP was assessed w i t h a dolor imeter.
Results: There was a significant improvement in both groups over t ime but there was no d i f fe r
ence between the t rea tment and cont ro l groups.
Conclusions: The use of a pressure d o l o r i m e t e r may have served as a f o r m of i schemic
compression t r ea tment . This assessment too l may have been a mit igat ing factor in the over
shadowing any po ten t i a l inf luence of the IASTT on the MTrP. Thus, another assessment too l
needs to be ident i f i ed for MTrP assessment. Unt i l t ha t techn ique is i den t i f i ed , the e f f e c t of
IASTT on MTrPs in inconclusive.
© 2014 Elsevier Ltd. All rights reserved.
Introduction
Tel.: +1 610 499 1287; fax: +1 610 499 1231. E-mail address: [email protected].
A myofasc ia l t r i gge r po i n t (MTrP) is a pa lpab le , hypersen
s i t i ve, nodu le w i t h i n a t a u t band of s ke le ta l musc le (Travel l
and Simons, 1989; A lverez and Rockwe l l , 2002). MTrPs can
deve lop f r o m st renuous or unaccus tomed a c t i v i t y as w e l l as
poor pos ture (Cheng, 1987). MTrPs can resu l t f o r any f o r m
http://dx.doi.Org/10.1016/j.jbmt.2014.02.004 1360-8592/© 2014 Elsevier Ltd. All rights reserved.
I n f luence o f i n s t r u m e n t assisted so f t t issue t r e a t m e n t techn iques on myofasc ia l t r i g g e - p c ' - i s
o f stress: m e n t a l or phys ica l . Tr igger po ints may deve lop
f r o m a c u t e i n j u r y or by c u m u l a t i v e m i c r o t r a u m a (Trave l l
and Simons, 1989). MTrPs can be a c t i v e o r l a t e n t . Ac t i ve
t r i g ge r po ints may be pa i n f u l a t t h e s i te of t h e t r i gge r po i n t
or may r e f e r pain t o an a d j a c e n t l o c a t i o n . Whereas l a t e n t
t r i gge r po ints t e n d t o ex i s t in a d o r m a n t s t a te and do not
p roduce d i s c omfo r t u n t i l t h e area is stressed. This stress
may man i f e s t in t h e f o r m of a f o r c e f u l musc le c o n t r a c t i o n
or a f i r m pa l pa t i on . A loca l t w i t c h response may occur via
an i n vo l un t a r y sp inal co rd re f lex w h e n t h e r e is a con t r ac
t i o n of t h e t a u t band. Whereas, pressure on t h e MTrP may
resu l t in a " j u m p s i g n " t h a t rad ia tes t o a zone of r e f e r ence
(Alverez and Rockwel l , 2002).
Chen e t a l . (2007) has shown t h a t s t i f fness of t h e t a u t
bands may be 50% g rea te r t han t h a t of t h e sur round ing
musc le t i ssue. This s t i f fness has been c o r r e l a t e d w i t h
muscle pa in , weakness, and l i m i t a t i o n s in m o t i o n (Graven-
Nielsen e t a l . , 1991; Hong and Simons, 1998; Mense, 1996,
1991, 1993; Simons e t a l . , 1995a, 1995b; Simons, 1996;
T rave l l and Simons, 1989).
The re are a v a r i e t y of moda l i t i e s p u r p o r t e d t o re l i eve or
d im in i sh t h e s ymptoms associated w i t h MTrPs. Massage
(Cantu and Grod in , 1992; Ebel and Wisham, 1952;
Pembe r t on , 1939; T rave l l and Simons, 1989), need l i ng
( H a m m e r o f f e t a l . , 1981; Hong and Simons, 1998; Jaeger
and Skootsky, 1987; L ew i t , 1997; Melzack, 1981; Melzack
e t a l . , 1977; T rave l l and Simons, 1989), vapocoo l an t spray
and s t r e t c h (Simons, 1996; T rave l l and Simons, 1989),
e l e c t r i c a l s t i m u l a t i o n (Hooker, 1998), laser t h e r a p y (Cheng,
1987; Laakson e t a l . , 1967), u l t ra sound (Draper and
P rent i ce , 1998; Draper e t a l . , 1995; Draper, 1996; Gam
e t a l . , 1998; Gul ick e t a l . , 1996; Srbely e t a l . , 2008;
Wi l l i ams e t a l . , 1987) and i schemic pressure (Gul ick
e t a l . , 2001, 2011) have a l l had va ry ing degrees of success.
I n s t r umen t Assisted Soft Tissue Techniques (IASTT) use
spec ia l stainless s tee l i n s t rument s w i t h beve led edges t o
assist t h e c l i n i c i an in t h e eva l ua t i on and m o b i l i z a t i o n of
so f t t issue (Looney e t a l . , 2011). I n s t ruments are used in a
m u l t i d i r e c t i o n a l s t rok ing fash ion app l i ed t o t h e skin a t
3 0 ° - 6 0 ° angles t o d e t e c t so f t t issue i r r egu l a r i t i e s v ia t h e
undu l a t i o n o f t h e too l s ( H o w i t t e t a l . , 2006; Sevier e t a l . ,
1995). In a d d i t i o n , IASTT has been p u r p o r t e d t o enhance
p r o l i f e r a t i o n of e x t r a c e l l u l a r m a t r i x f ib rob las t s , imp rove
ion t r an spo r t , and decrease c e l l m a t r i x adhesions (Gehlsen
e t a l . , 1999; Hammer and Pfefer , 2005; H o w i t t e t a l . , 2006;
Loghmani and Warden, 2009). IASTT has been suggested t o
be use fu l in t h e t r e a t m e n t o f chron ic f ibrosis, l a t e r a l e p i
condy l i t i s , ca rpa l t u n n e l s yndrome, t r i gge r t h u m b , and
p l a n t a r fasc i t i s ( H o w i t t e t a l . , 2006; Leahy, 1995; Me lham
e t a l . , 1998; Sevier e t a l . , 1995). However, t h e e f f e c t s of
t h e IASTT on MTrPs have no t been e xp l o r ed . This s tudy was
i n t e n d e d t o be t h e f i r s t r andom i zed , c o n t r o l l e d , IASTT
s tudy using a prev ious ly deve l oped p r o t o c o l (Gul ick e t a l . ,
2011) t o examine t h e i n f l uence on MTrPs.
Methods
The inves t i ga to r of th is s tudy is a Graston Techn ique (GT)
t r a i n e d c l i n i c i an and educa t o r w i t h a p p r o x i m a t e l y 1.5 years
of IASTT expe r i ence . The methodo l ogy of th is s tudy was
deve l oped in con su l t a t i on w i t h t h e GT c l i n i c a l advisor. She
Figure 1 Myofascial tr igger point assessment technique.
no t on ly r e c o m m e n d e d t h e strokes, t r e a t m e n t d u r a t i o n ,
and spec i f ic i n s t r ument s t o be used, b u t she p rov ided a
v ideo d e m o n s t r a t i o n of t h e way GT teaches t h e ski l ls. This
was h e l p f u l in t h e e s t ab l i s hment of a s tandard i zed t r e a t
m e n t p r o t o c o l .
As a re su l t o f t h e i n i t i a l da ta c o l l e c t e d in phase one, th i s
s tudy evo l ved i n t o a t w o phase methodo logy . When t h e
p o t e n t i a l p a r t i c i p an t s responded t o a pos ted f lyer , t h e
research assistant i nqu i r ed abou t t h e presence of " k n o t s "
( i .e. MTrP) in t h e neck and upper back reg ion. If t h e po
t e n t i a l p a r t i c i p a n t had knot( s ) and was no t rece iv ing any
t r e a t m e n t t o th i s a rea, he/she was asked t o sign a consent
f o r m approved by t h e Univers i ty I n s t i t u t i o na l Review Board.
To sat i s fy t h e exc lus ion c r i t e r i a , each p a r t i c i p a n t was
screened f o r sensory p rob lems in t h e upper or m idback
regions, h e a r t / c i r c u l a t i o n p rob lems, cancer, d i abe te s
me l l i t u s , tubercu los i s , and shoulder, neck, or u p p e r / m i d -
back surgeries. The uppe r /m idback reg ion was i n spec ted
f o r wounds , lesions, and i n fec t i on s . The pa r t i c i pan t s w e r e
seated in a cha i r w i t h h is/her f o rea rms res t ing on a t r e a t
m e n t t a b l e and f o rehead on t h e f o rea rms . MTrPs w e r e
i d e n t i f i e d by manua l pa l pa t i on of t a u t musc le bands in t h e
upper back w i t h t h e presence of a " j u m p s i gn " and r e f e r r e d
pain w h e n pressure was app l i ed . This task was p e r f o r m e d
by a l icensed c l i n i c i an (DTG) w i t h 30 years o f c l i n i c a l
e xpe r i ence . An a l g o m e t e r / d o l o r i m e t e r (JTECH Company,
Salt Lake City, UT) w i t h a 1-cm d i a m e t e r t i p was used t o
measure pressure sens i t i v i t y (in grams) of t h e MTrPs. Test-
re te s t r e l i a b i l i t y of th i s i n s t r u m e n t in assessing musc le
soreness is r e p o r t e d t o be r = 0.91—0.95 (Gul ick e t a l . ,
1996; McCarty e t a l . , 1965).
Phase 1
Phase 1 i n c l uded hea l t hy pa r t i c i p an t s (n = 27; 13 ma le , 14
f e m a l e ; age = 23.88 ± 1.13; h t = 167.98 ± 10.13 c m ;
W t = 69.26 ± 14.19 kg) r e c r u i t e d by a f lyer. Phase 1 used
t w o MTrPs in t h e upper back. When possible, MTrPs w e r e
D.T. Gul ick
:e e: :ez - : : : " £ = : : a -d ing musc le group on bo th t h e r i gh t
.=-": vzai. e.g. right and l e f t upper t rapez iu s muscles.
If t h i s M S not possible, an a d j a c e n t musc le on t h e
: : - : - = . = : 5 " = . s e e was used, e.g. r i gh t upper t rapez iu s and
e ~ =•=:;- s i apu l a musc le. The d o l o r i m e t e r was p laced on
== : - s-:d pressure was s lowly app l i ed by t h e i nve s t i -
zi'z' --g..re 1i u n t i l t he p a r t i c i p a n t r e p o r t e d t h a t t h e
: - e : ; ^ " e reached t h e th re sho ld of d i s c o m f o r t ( p r e - t r e a t -
~ e ~ t i . The measurements w e r e reco rded by a research
assistant so t h a t t h e t e s t e r was b l i nded t o t h e measure-
—ent s . The MTrPs w e r e t h e n ma r ked w i t h a Sharpie® f o r
subsequent re-tests .
Par t i c ipant s w e r e assigned a numbe r f o r da ta c o l l e c t i o n
purposes. Par t i c ipants w i t h an odd n u m b e r had t h e r i ght
MTrP t r e a t e d and those assigned an even numbe r had t h e
l e f t MTrP t r e a t e d . The c o n t r a l a t e r a l MTrP served as t h e
c o n t r o l . On Day 1, t r e a t m e n t r ende red via t h e Graston
Techn ique i nvo l ved 1-min o f sweep ing t h e upper back re
gion (GT-1), 1-min o f sw ive l i ng d i r e c t l y over t h e MTrP (GT-
1), t h e n 2 -min o f f ann i n g t h e MTrP and su r round ing tissues
in a l l d i r ec t i on s (GT-4) and f i na l l y 1-min of sweep ing (GT-1)
of t h e upper back reg ion. Sweeping (Fig. 2) is a l o ng i t ud i na l
s t roke p e r f o r m e d pa ra l l e l t o t h e musc le f ibers . Swivel ing
(Fig. 3) is a t e c h n i q u e in w h i c h t h e knob of t h e GT-1 i n
s t r u m e n t is p laced d i r e c t l y on t h e MTrP and p i v o t e d /
r o t a t e d back and f o r t h . F inal ly, f ann ing (Fig. 4) is a s t roke
in w h i c h one end o f t h e GT-4 i n s t r u m e n t is he ld in p lace and
t h e o t h e r end is moved in a c i r c u l a r p a t t e r n in t h e shape of
a f a n .
Thus, in keep ing w i t h t h e GT r e c o m m e n d a t i o n , a t o t a l o f
5-min of t r e a t m e n t w e r e p rov ided t o t h e ove ra l l reg ion.
The i n s t rument s w e r e m a i n t a i n e d a t a 30—60° angle
t h r o u g h o u t t h e sweep ing and fann ing techn iques . Six
t r e a t m e n t s ( t w o - t i m e s per w e e k ) w e r e p e r f o r m e d over a
Figure 3
w i t h GT1.
Instrument assisted soft tissue technique - swivel
F igure 2 Instrument assisted soft tissue technique
w i t h GT1. sweep
t h r e e w e e k pe r iod w i t h a t least t w o days b e t w e e n t r e a t
ments . A lmost a l l t r e a t m e n t s w e r e r ende red on a Monday
(AM)/Thursday (PM) or Tuesday (AM)/Friday (PM) schedule.
This t r e a t m e n t i n t e r v a l was t h e r e c o m m e n d a t i o n of t h e GT.
On t w o occasions, a schedu l ing c o n f l i c t r e su l ted in a
p a r t i c i p a n t schedu led on a Monday be ing t r e a t e d on
Tuesday so t hey s tayed on t h e Tuesday/Fr iday schedu le t o
m a i n t a i n t h e a p p r o p r i a t e t r e a t m e n t spacing. Retest ing
using t h e d o l o r i m e t e r was c o m p l e t e d a f t e r t r e a t m e n t #6
( p o s t - t r e a t m e n t ) as w e l l as 3 - 4 days a f t e r t r e a t m e n t
conc luded ( f o l l o w - u p ) .
Phase 2
Phase 2 i n c l uded hea l t hy p a r t i c i p an t s (n = 22; 5 ma l e , 17
f e m a l e ; age = 24.82 ± 3.19; h t = 164.33 ± 9.55 c m ;
W t = 64.55 ± 11.37 kg). The p r ima r y d i f f e r e n c e in phase 2
was t h e use of on ly one MTrP per p a r t i c i p a n t . Thus, t h e r e
was a t r e a t m e n t (n = 14) and a c o n t r o l (n = 8) g roup (A-B-
A design). Do l o r ime te r measures w e r e t a ken every o t h e r
day f o r 5 basel ine values. The same IASTT descr ibed in
phase 1 was r ende red t o t h e t r e a t m e n t group over t h r e e
weeks ( t w o t imes per w e e k x 3 weeks = 6 t r e a t m e n t s ) .
The c o n t r o l g roup d i d n o t rece i ve any i n t e r v e n t i o n . The
MTrPs of b o t h groups w e r e assessed each session th rough
t h e t r e a t m e n t phase, and t h e n assessed f ive t imes (every
o t h e r day) du r i ng t h e p o s t - t r e a t m e n t phase. The MTrPs
w e r e marked w i t h a Sharpie® t o c o n f i r m t h e l o ca t i on of
subsequent re-tests .
Under most c l i n i c a l cond i t i on s , a d d i t i o n a l i n t e r ven t i on s
w o u l d most l i ke l y be e m p l o y e d . However, p e r f o r m i n g any
a d d i t i o n a l i n t e r ven t i on s cou ld make genera l i za t ions abou t
605
Figure 4
w i t h GT4.
Instrument assisted soft tissue technique — fan
t h e e f fec t i venes s of IASTT d i f f i c u l t . So, t h r o u g h o u t bo th
phases of t h e study, pa r t i c i p an t s w e r e i n s t r u c t ed no t t o
render any o t h e r t r e a t m e n t t o t h e upper back reg ion.
Par t i c ipant s w e r e ques t i oned at each t r e a t m e n t session t o
c o n f i r m comp l i ance .
Results
For phase 1, a r epea ted measures ANOVA revea led no sig
n i f i c an t d i f f e r e n c e b e t w e e n t h e groups (p = 0.497), but
t h e r e was a s i gn i f i cant d i f f e r e n c e over t i m e (p < 0.001).
Con t r o l MTrPs increased pressure t o l e r ance by 3.7 g f r o m
p r e - t r e a t m e n t t o p o s t - t r e a t m e n t and 0.9 g f r o m post-
t r e a t m e n t t o f o l l o w - u p . E xpe r imen ta l MTrPs imp roved
6.2 g f r o m p r e - t r e a t m e n t t o p o s t - t r e a t m e n t and 0.1 g f r o m
p o s t - t r e a t m e n t t o f o l l o w - u p (Fig. 5)
For phase 2, t h e r e was a s imi la r t r e n d in t h e pressure
t o l e r a n c e of t h e t r e a t m e n t and t h e c o n t r o l groups (Fig. 6).
29.00
27.00
25.00
23.00
21.00
19.00
17.00
15.00
Pre-Treatment Post-Treatment Follow-Up
Figure 5 Graph of phase 1 myofascial tr igger point sensi
t i v i t y between contro l and instrument assisted soft tissue
technique.
CO CD CQ
Figure 6 Graph of phase 2 myofascial tr igger point se~s ;-
t i v i t y between contro l and inst rument assisted soft t ;ssue
technique.
Thus, t h e r e was no s ign i f i cant d i f f e r e n c e b e t w e e n the
groups bu t t h e r e was a d i f f e r e n c e over t i m e . In b o t h phases
of th is methodo logy , t h e r e was m i l d e r y t h e m a over t he
MTrPs f o l l o w i n g t h e sw ive l ing t e c h n i q u e and m i l d pe tech i ae
over t h e upper back region by t h e conclus ion of t h e t r e a t
m e n t . There was never any ecchymosis.
Discussion
Pain and dy s func t i on associated w i t h a MTrPs can s igni f i
c an t l y a f f e c t q u a l i t y of l i f e (Graven-Nielson e t a l . , 1991;
Hong and Simon, 1998; Mense, 1991, 1993, 1996; Simons.
Hong, & Simons, 1995; Simons, 1996; T rave l l and Simons,
1989). Despite t h e results of th i s study, IASTT may be an
e f f e c t i v e t r e a t m e n t f o r MTrPs. In phase 1, i m p r o v e m e n t of
b o t h groups may have been due t o a systemic response w i t h
t h e t r e a t e d MTrP car ry ing -over t o t h e c o n t r a l a t e r a l side.
Perhaps t h e IASTT f a c i l i t a t e d t h e release of neuro t rans
m i t t e r s t o aba te t h e d i s c omfo r t b i l a t e r a l l y . Or perhaps t he
l inkages of t h e muscular and fasc ia l systems not only
decreased t h e sens i t i v i t y on t h e t r e a t e d side, bu t also
c o n t r i b u t e d t o t h e r e d u c t i o n of d i s c omfo r t on t h e c on t r a
l a t e r a l s ide.
Seeing th i s weakness in t h e methodo logy of phase 1. t he
i nves t i ga to r e m b a r k e d on phase 2. The second phase
emp l o yed a r andomized c o n t r o l w i t h an A-B-A design.
Baseline measu rement s (A) of MTrP d i s c omfo r t w e r e ob
t a i ned p r i o r t o r ende r i ng six t r e a t m e n t s (B). The f o l l o w - u p
(A) was p e r f o r m e d t o i nve s t i ga te t h e p o t e n t i a l ca r ry -over zf
t h e t r e a t m e n t . Phase 2 was i n t e n d e d t o e l i m i n a t e t h e iss-e
of a cross-over e f f e c t of IASTT wh i ch may have zee- =
m i t i g a t i n g f a c t o r in phase 1. However, t h e s imi la r d o p e
(Fig. 6) of t h e t r e a t m e n t and c o n t r o l groups was _ : t ex
p e c t e d . The one i t e m bo th groups had in c o m m o " •••'as :~e
te s t i ng t e c h n i q u e w i t h t he d o l o r i m e t e r . It appea-s t ' - = : :~e
te s t i ng t e c h n i q u e used t o assess MTrP d iscom-"c~ —=.. ~z e
i n f l uenced t h e c o n t r o l g roup, as w e l l as t he e x : £ ~ _ e ~ : 3
group t o imp rove t h e pain th re sho ld of t h e M.T'?. zzzz
is cons i s tent w i t h a p r i o r s tudy by Gu l i ck e t a l . (2011) w h e r e
i schemic pressure w i t h a Backnobber I! c c e : : : zezezie
MTrP sens i t i v i t y w i t h six 30-s compress:o-s zez-e-ez s m
o t h e r day f o r a w e e k (4 t r e a t m e n t sess ::-s . ' z~e z e:z'
study, t h e use of t h e d o l o r i m e t e r to sssess :ezzz ' t
i nvo lved t h r e e compress ion m o v e s zzz~z •~— = Zz l-z:
D.T. Gul ick
£ E : - 5 _ \ - t h e p r i o r s tudy w h e r e i m p r o v e m e n t was
-z'.ez =-':=" "'pur t r e a t m e n t s , t h e upwa rd t r a j e c t o r y of t h e
i ~ i g e - p-p\-t sens ; t i v i t y occu r red by t h e 5th ( con t ro l ) and
::- t ' 5 2 : ~ e r t i measurements . This supports t h e h y p o t h -
z-yz by Simons [1995a, 1995b, 1996) t h a t MTrPs a re in an
~e~= ' i , . c s V and i schemic compress ion may i n t e r r u p t t h e
patho logy of t h e MTrP w i t h a r eac t i ve hype remia
••-stppoulos e t a l . , 2008). Perhaps t h e f r equency of t he
assessment of t he MTrP should have been less f r e q u e n t .
3 - c e basel ine was e s tab l i shed, p r e - t r e a t m e n t , p o s t - t r e a t -
— e n t , and one f o l l o w - u p t w o weeks l a t e r may have been
su f f i c i en t . The i n t e n t o f t h e m u l t i p l e measures was t o not
on l y see i f an e f f e c t occurs b u t w h e n i t o c cu r r ed .
Even w i t h th is con found ing i n f l uence , t h e e x p e r i m e n t a l
group d id i m p r o v e a b i t mo re t han t h e c o n t r o l b u t t h e e f
f e c t size was no t enough t o y i e l d s t a t i s t i c a l s ign i f icance.
Despite t h e r e commenda t i on s o f GT on t h e p r o t o c o l of th is
study, t h e r e is no " p r o v e n " IASTT f o r MTrPs. Perhaps
d i f f e r e n t strokes using d i f f e r e n t i n s t r ument s f o r d i f f e r e n c e
per iods of t i m e may be in order. Final ly, a l though MTrPs
have a p ropens i t y t o reoccur, i t is beyond t h e scope o f th is
s tudy t o c o m m e n t on long t e r m e f f e c t s .
Conclusions
The c u r r e n t s tudy was i n t e n d e d t o be t h e f i r s t r andom i zed ,
c o n t r o l l e d s tudy t o e xam ine t h e e f f e c t o f IASTT on MTrPs.
Despite a me thodo l o g i c a l change t o address one conce rn ,
t h e d o l o r i m e t e r t e c h n i q u e ( f r equency of measures) may
have been t h e m i t i g a t i n g f a c t o r in t h e assessment of t h e
IASTT. The re needs t o be f u r t h e r e x p l o r a t i o n i n t o a no the r
e x a m i n a t i o n t e c h n i q u e o f a MTrP response t o t r e a t m e n t .
Perhaps range of m o t i o n or s t reng th te s t i ng of t h e musc le in
w h i c h t h e MTrP is l o ca ted w o u l d p rov ide i n f o r m a t i o n abou t
the response t o t r e a t m e n t w i t h o u t d i r e c t l y t ouch i ng t h e
MTrP. In a d d i t i o n , t he rmog r aphy may p rov ide an i n d i r e c t
measure o f b l ood f l o w t o t h e area. U n t i l such a t e c h n i q u e is
: d e n t i f i e d , t h e e f f e c t o f IASTT on MTrPs in inconc lus ive.
Acknowledgements
~ _ e author w o u l d l i ke t o t hank t h e f o l l o w i n g g r adua te
: :_cent s f o r t h e assistance in Phase 1 o f th is research:
I — s t p p h e r A. E lwe l l , An thony J. F i t t i p a l d i , M ichae l A.
~ . - : = - s . Lesasha M. S tewar t , Kath leen P. Tarpey, Joshua
I e"-es. The au tho r w o u l d also l i ke t o thank Robert
e - : - PT, NCS fo r his s t a t i s t i c a l c on su l t a t i on .
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