Trigger point manual therapy for the treatment of chronic noncancer pain in adults: a systematic review and meta-analysis

Key points

1. 01No significant short-term pain relief: pooled SMD -0.5 (95% CI -1.0 to 0.4) across 11 studies
2. 02One small study showed longer-term pain benefit at 6 months (SMD -2.0, 95% CI -3.4 to -0.6) but with low certainty
3. 03Function improved significantly across 15 studies (SMD -0.6, 95% CI -1.1 to -0.2, p=0.003)
4. 04Patient global assessment favoured treatment (OR 3.79, 95% CI 1.86 to 7.71) in 4 studies
5. 05GRADE quality of evidence was low for all primary outcomes due to small sample sizes and high heterogeneity

How it was conducted

Design

Systematic review and meta-analysis of randomised controlled trials

Search

MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, AMED, LILACS, PEDro, Web of Science, SCOPUS and others from inception to May (search updated May)

Participants

Adults aged over 18 with pain of 3 months duration or more; 1,047 participants across included trials

Intervention

Trigger point manual therapy (TPMT) - sustained digital pressure or myofascial release techniques targeting trigger points using ischaemic compression

Comparators

Placebo/sham, waiting list, dry needling, or other forms of manual therapy

Primary outcomes

Pain relief, functional outcomes, patient-reported improvement, health-related quality of life, adverse events, withdrawals

What they found

• Short-term pain relief (11 studies, participants not fully specified): SMD -0.5 (95% CI -1.0 to 0.4) - no significant effect; heterogeneity I2 very high
• Sensitivity analysis (studies with low risk of bias for sample size): SMD -1.7 (95% CI -3.4 to 0.0) - non-significant
• Long-term pain at 6 months (1 study, 9 participants): SMD -2.0 (95% CI -3.4 to -0.6) - significant but low certainty
• Function (15 studies, 8 participants): SMD -0.6 (95% CI -1.1 to -0.2), z=2.93, p=0.003 - significant improvement; I2 very high
• Patient global assessment (4 studies): OR 3.79 (95% CI 1.86 to 7.71) - significantly favours TPMT; 68% improved in intervention vs 37% in control groups
• Health-related quality of life (3 studies): mean difference -2.0 (95% CI -6.1 to 1.1) - no significant benefit
• Adverse events (3 studies): OR 2.05 (95% CI 0.85 to 4.73) - no significant excess adverse events
• Withdrawals (1047 participants): OR 0.57 (95% CI 0.41 to 1.14) - no significant difference; overall withdrawal rate 3%

Limitations

• All but one study had no follow-up beyond end of treatment, making durability of any benefit unknown
• Most included studies were underpowered: only 8 of 18 achieved their target sample size; risk of Type I error in small trials is high
• High heterogeneity (I2 very high for both pain and function) across varied conditions and body regions limits pooled conclusions
• Only 2 of 18 studies reported clear clinical diagnostic criteria for trigger points, raising questions about diagnostic consistency across trials

Why it matters

For patients

People with chronic musculoskeletal, pelvic, or facial pain should be aware that the current evidence does not support trigger point manual therapy as a stand-alone treatment for reducing pain, even though some patients report feeling better overall and may experience short-term functional gains.

For clinicians

Trigger point manual therapy cannot currently be recommended as a stand-alone treatment for chronic non-cancer pain; if used at all, it should be part of a multimodal programme, and clinicians should ensure adequate sample size and long-term follow-up in future trials.

For readers

This review highlights a recurring problem in manual therapy research: studies are too small, too short, and too varied in methods to draw firm conclusions, underscoring the need for well-powered, adequately followed-up RCTs before this widely used technique can be endorsed or dismissed.