You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients.
Abstract 1:
OBJECTIVES To compare the efficacies of dry needling of trigger points ( TrPs ) with and without paraspinal needling in myofascial pain syndrome of elderly patients . DESIGN Single-blinded , r and omized controlled trial . SUBJECTS Forty ( 40 ) subjects , between the ages of 63 and 90 with myofascial pain syndrome of the upper trapezius muscle . INTERVENTIONS Eighteen ( 18 ) subjects were treated with dry needling of all the TrPs only and another 22 with additional paraspinal needling on days 0 , 7 , and 14 . RESULTS At 4-week follow-up the results were as follows : ( 1 ) TrP and paraspinal dry needling result ed in more continuous subjective pain reduction than TrP dry needling only ; ( 2 ) TrP and paraspinal dry needling result ed in significant improvements on the geriatric depression scale but TrP dry needling only did not ; ( 3 ) TrP and paraspinal dry needling result ed in improvements of all the cervical range of motions but TrP dry needling  only did not in extensional cervical range of motion ; and ( 4 ) no cases of gross hemorrhage were noted . CONCLUSIONS TrP and paraspinal dry needling is suggested to be a better method than TrP dry needling only for treating myofascial pain syndrome in elderly patients


Title 2:
Management of Myofascial Pain of Upper Trapezius: A Three Group Comparison Study
Abstract 2:
It is important to identify the most effective therapeutic modality in the management of myofascial trigger points ( MTPt ) . Thus we aim ed to study the effect of therapeutic ultrasound , laser and ischemic compression in reducing pain and improving cervical range of motion among patients with MTPt . Experimental study comparing three groups was design ed as a 5 days trial , a co-relational design was considered . Outcome measures : VAS for pain , provocative pain test using “ soft tissue tenderness grading scheme ” and active cervical lateral flexion using inch tape . Methods - Patients were divided into 3 groups , Gr 1 underwent treatment using therapeutic ultrasound , Gr 2 with therapeutic laser and Gr 3 with ischemic compression . Assessment s were done on day 1 and day 5 of treatment respectively . Results : ANOVA revealed improvement among all 3 groups as statistically significant difference ( p<0.05 ) between the start and end of trial . Analysis using Chi square test shows a statistically significant difference in the improvement between laser and the other 2 groups . Mean difference in the change of scores between the assessment s showed laser therapy to have a tendency towards progressive improvement over the treatment period and a better improvement than the other 2 groups . Weconclude that laser can be used as an effective treatment regimen in the management of myofascial trigger points thereby reducing disability caused due to musculoskeletal pathology


Title 3:
Skeletal muscle contractility, self-reported pain and tissue sensitivity in females with neck/shoulder pain and upper Trapezius myofascial trigger points– a randomized intervention study
Abstract 3:
Background In relation to Myofascial Triggerpoints ( MFTrPs ) of the upper Trapezius , this study explored muscle contractility characteristics , the occurrence of post-intervention muscle soreness and the effect of dry needling on muscle contractile characteristics and clinical outcomes . Methods Seventy-seven female office workers ( 25 - 46yrs ) with and without neck/shoulder pain were observed with respect to self-reported pain ( NRS-101 ) , pressure-pain threshold ( PPT ) , maximum voluntary contraction ( Fmax ) and rate of force development ( RFD ) at baseline ( pre-intervention ) , immediately post-intervention and 48 hours post-intervention . Symptomatic and asymptomatic participant groups were each r and omized into two treatment sub-groups ( superficial ( SDN ) and deep dry needling ( DDN ) ) after baseline testing . At 48 hours post-intervention participants were asked whether delayed onset muscle soreness ( DOMS ) and /or post-needling soreness had developed . Results Muscle contractile characteristics did not differ between groups at baseline . Forty-six individuals developed muscle soreness ( 39 from mechanical testing and seven from needling ) . No inter-group differences were observed post-intervention for Fmax or RFD for the four sub-groups . Over the observation period , symptomatic participants reported less pain from both SDN ( p= 0.003 ) and DDN ( p=0.011 ) . However , PPT levels were reduced for all participants ( p=0.029 ) . Those reporting DOMS experienced significant decreases in PPT , irrespective of symptom state or intervention ( p=0.001 ) . Conclusions In selected female neck/shoulder pain sufferers , maximum voluntary contraction and rapid force generation of the upper Trapezius was not influenced by clinical ly relevant self-reported pain or the presence of diagnostically relevant MFTrPs . Dry needling , deep or superficial , did not affect measured functional outcomes over the 48-hour observation period . DOMS affected participants uniformly irrespective of pain , MFTrP status or intervention type and therefore is like to act as a modifier . Trial registration Clinical Trials.gov- NCT01710735 Significance and InnovationsThe present investigation is one of the first to examine the hypothesis of gross muscle contractile inhibition due to the presence of diagnostically relevant MFTrPs . Individuals suffering from clinical ly relevant levels of self-reported pain are able to tolerate maximum voluntary contraction testing , but delayed onset muscle soreness ( DOMS ) is a likely side-effect irrespective of symptom status . As a consequence , its confounding effect during subsequent testing must be taken into account


Title 4:
Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial
Abstract 4:
In this study ; we aim ed to compare the efficacy of local anesthetic injection and dry needling methods on pain , cervical range of motion ( ROM ) , and depression in myofascial pain syndrome patients ( MPS ) . This study was design ed as a prospect i ve r and omized controlled study . Eighty patients ( female 52/male 28 ) admitted to a physical medicine and rehabilitation outpatient clinic diagnosed as MPS were included in the study . Patients were r and omly assigned into two groups . Group 1 ( n = 40 ) received local anesthetic injection ( 2 ml lidocaine of 1 % ) and group 2 ( n = 40 ) received dry injecting on trigger points . Both patient groups were given stretching exercises aim ed at the trapezius muscle to be applied at home . Patients were evaluated according to pain , cervical ROM , and depression . Pain was assessed using Visual Analog Scale ( VAS ) and active cervical ROM was measured using goniometry . Beck Depression Inventory ( BDI ) was used to assess the level of depression . There were no statistically significant differences in the pre-treatment evaluation parameters of the patients . There were statistically significant improvements in VAS , cervical ROM , and BDI scores after 4 and 12 weeks in both groups compared to pre-treatment results ( p < 0.05 ) . No significant differences were observed between the groups ( p > 0.05 ) . Our study indicated that exercise associated with local anesthetic and dry needling injections were effective in decrease of pain level in MPS as well as increase of cervical ROM and decrease of depressive mood levels of individuals


Title 5:
LIDOCAINE INJECTION VERSUS DRY NEEDLING TO MYOFASCIAL TRIGGER POINT: The Importance of the Local Twitch Response
Abstract 5:
This study was design ed to investigate the effects of injection with a local anesthetic agent or dry needling into a myofascial trigger point ( TrP ) of the upper trapezius muscle in 58 patients .  Trigger point injections with 0.5 % lidocaine were given to 26 patients ( Group I ) , and dry needling was performed on TrPs in 15 patients ( Group II ) . Local twitch responses ( LTRs ) were elicited during multiple needle insertions in both Groups I and II . In another 17 patients , no LTR was elicited during TrP injection with lidocaine ( 9 patients , group Ia ) or dry needling ( 8 patients , group IIa ) . Improvement was assessed by measuring the subjective pain intensity , the pain threshold of the TrP and the range of motion of the cervical spine . Significant improvement occurred immediately after injection into the patients in both group I and group II . In Groups la and Ib , there was little change in pain , tenderness or tightness after injection . Within 2 - 8 h after injection or dry needling , soreness ( different from patients ' original myofascial pain ) developed in 42 % of the patients in group I and in 100 % of the patients in group II . Patients treated with dry needling had postinjection soreness of significantly greater intensity and longer duration than those treated with lidocaine injection . The author concludes that it is essential to elicit LTRs during injection to obtain an immediately desirable effect . TrP injection with 0.5 % lidocaine is recommended , because it reduces the intensity and duration of postinjection soreness compared with that produced by dry


Title 6:
The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial
Abstract 6:
Abstract Currently , large levels of practice variability exist regarding the clinical deactivation of trigger points . Manual physical therapy has been identified as a potential means of resolving active trigger points ; however , to date the ideal treatment approach has yet to be eluci date d. The purpose of this clinical trial was to compare the effects of two manual treatment regimens on individuals with upper trapezius trigger points . Sixty patients , 19–38 years of age with non-specific neck pain and upper trapezius trigger points , were r and omized into one of two , 4 week physical therapy programs . One group received muscle energy techniques while the second group received an integrated neuromuscular inhibition technique ( INIT ) consisting of muscle energy techniques , ischemic compression , and strain – counterstrain ( SCS ) . Outcomes including a visual analog pain scale ( VAS ) , the neck disability index ( NDI ) , and lateral cervical flexion range of motion ( ROM ) were collected at baseline , 2 and 4 weeks after the initiation of therapy . Results revealed large pre – post-effect sizes within the INIT group ( Cohen 's d = 0.97 , 0.94 and 0.97 ) . Additionally , significantly greater improvements in pain and neck disability and lateral cervical flexion ROM were detected in favor of the INIT group ( 0.29–0.57 , 0.57–1.12 and 0.29–0.57 ) at a 95 % CI respectively . The findings of this study indicate the potential benefit of an integrated approach in deactivating upper trapezius trigger points . Further research should be performed to investigate the long-term benefits of the current treatment approach


Title 7:
Comparison of Superficial and Deep Acupuncture in the Treatment of Lumbar Myofascial Pain: A Double-Blind Randomized Controlled Study
Abstract 7:
Objective The aim of the study was to compare the therapeutic effect of the superficial and in-depth insertion of acupuncture needles in the treatment of patients with chronic lumbar myofascial pain . Design A prospect i ve r and omized double-blind study of superficial and deep acupuncture was conducted . Setting The study was conducted in the Pain Service Unit of the University of Padova . Patients The study comprised 42 patients with lumbar myofascial pain who were divided into two equal groups ( A and B ) . InterventionIn group A , the needle was introduced in the skin at a depth of 2 mm , whereas in group B the needle was placed deeply into muscular tissue . The treatment was planned for a cycle of eight sessions . Outcome Measures The intensity of pain was evaluated with the McGill Pain Question naire before and after treatment and at the 3-month follow-up examination . Results Although at the end of the treatment there was no evidence of significant statistical differences between the two different groups , pain reduction was greater in the group treated with deep acupuncture . A statistical difference existed between the two groups at the 3-month follow up , with a better result in the deeply stimulated group . Conclusions Clinical results show that deep stimulation has a better analgesic effect when compared with superficial stimulation


Title 8:
Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points.
Abstract 8:
BACKGROUND AND PURPOSE Myofascial trigger points ( TPs ) are found among patients who have neck and upper back pain . The purpose of this study was to determine the effectiveness of a home program of ischemic pressure followed by sustained stretching for the treatment of myofascial TPs . SUBJECTS Forty adults ( 17 male , 23 female ) , aged 23 to 58 years ( mean=30.6 , SD=9.3 ) , with one or more TPs in the neck or upper back participated in this study . METHODS Subjects were r and omly divided into 2 groups receiving a 5-day home program of either ischemic pressure followed by general sustained stretching of the neck and upper back musculature or a control treatment of active range of motion . Measurements were obtained before the subjects received the home program instruction and on the third day after they discontinued treatment . Trigger point sensitivity was measured with a pressure algometer as pressure pain threshold ( PPT ) . Average pain intensity for a 24-hour period was scored on a visual analog scale ( VAS ) . Subjects also reported the percentage of time in pain over a 24-hour period . A multivariate analysis of covariance , with the pretests as the covariates , was performed and followed by 3 analyses of covariance , 1 for each variable . RESULTS Differences were found between the treatment and control groups for VAS scores and PPT . No difference was found between the groups for percentage of time in pain . CONCLUSION AND DISCUSSION A home program , consisting of ischemic pressure and sustained stretching , was shown to be effective in reducing TP sensitivity and pain intensity in individuals with neck and upper back pain . The results of this study indicate that clinicians can treat myofascial TPs through monitoring of a home program of ischemic pressure and stretching
There is moderate evidence for  ischemic compression and strong evidence for dry needling to have a positive effect on pain intensity .
This pain decrease is greater compared with active range of motion exercises ( ischemic compression ) and no or placebo intervention ( ischemic compression and dry needling ) but similar to other therapeutic approaches .
There is moderate evidence that both ischemic compression and dry needling increase side-bending range of motion , with similar effects compared with lidocaine injection .
There is weak evidence regarding its effects on functionality and quality -of-life .
On the basis of this systematic review , ischemic compression and dry needling can both be recommended in the treatment of neck pain patients with trigger points in the upper trapezius muscle .