Comparative effectiveness of noninvasive therapeutic interventions for myofascial pain syndrome: a network meta-analysis of randomized controlled trials

Myofascial pain syndrome (MPS) is a common chronic musculoskeletal condition affecting 30-85% of patients with musculoskeletal pain. It originates from myofascial trigger points and causes significant pain, disability, and reduced quality of life. While various noninvasive treatments exist for MPS, the relative effectiveness of different approaches has not been comprehensively compared. Previous systematic reviews have only examined pairs of treatments rather than comparing all available options simultaneously.

The researchers conducted a network meta-analysis by searching six major databases for randomized controlled trials comparing noninvasive treatments for MPS. They included 40 studies with 2,227 participants and analyzed 11 different treatment types: manual therapy, laser therapy, extracorporeal shock wave therapy, ultrasound, electrical nerve stimulation, exercise, medication, Kinesio taping, heat therapy, far-infrared ray, and combination therapies. The primary outcome was pain intensity measured on visual analog or numeric rating scales. Secondary outcomes included pressure pain threshold (measured with algometry) and pain-related disability (measured with neck disability index or similar scales).

The network meta-analysis allowed for both direct comparisons (when treatments were compared head-to-head in trials) and indirect comparisons (when treatments were compared through common comparators like placebo).

Five treatments showed statistically significant benefits compared to control/placebo for reducing pain intensity: manual therapy (mean difference -1.60, 95% CI -2.17 to -1.03), laser therapy (MD -1.15, 95% CI -1.83 to -0.46), extracorporeal shock wave therapy (MD -1.61, 95% CI -2.43 to -0.78), ultrasound therapy (MD -1.54, 95% CI -2.24 to -0.84), and combination therapy (MD -1.67, 95% CI -2.90 to -0.44). For pressure pain threshold improvement, manual therapy, laser therapy, extracorporeal shock wave therapy, and ultrasound all showed significant benefits. For reducing pain-related disability, manual therapy, laser therapy, and extracorporeal shock wave therapy were most effective. When comparing treatments directly against each other (rather than against placebo), laser therapy was superior to far-infrared ray for pressure pain threshold, and both manual therapy and extracorporeal shock wave therapy were more effective than heat therapy for reducing disability.

Combined therapy had the highest probability of being the most effective treatment for pain intensity (32% probability), though manual therapy had the largest area under the curve (79.4%).

This analysis provides clinicians with evidence-based guidance for selecting among noninvasive treatments for patients with myofascial pain syndrome. Manual therapy, laser therapy, and extracorporeal shock wave therapy emerged as the most versatile options, showing benefits across all three outcome measures (pain, pressure sensitivity, and disability). These findings suggest that any of these three treatments could be prioritized when addressing multiple symptoms simultaneously. However, the evidence quality was rated as low to moderate according to GRADE criteria, primarily due to difficulty blinding participants and small sample sizes in some studies.

The clinical significance of the improvements, while statistically significant, was modest - with pain reductions of 1-2 points on 10-point scales. Future high-quality randomized controlled trials are needed to confirm these findings and establish optimal treatment protocols.