ARTICLE

Efficacy of Immediate Rewarming with Moist Heat AfterConventional Vapocoolant Spray Therapy in Myofascial

Pain Syndrome

Cengiz Bahadır, MD, MSVildan Yaman Dayan, MD

Feride Ocak, MDSemra Yigit, MD

ABSTRACT. Objectives: Spray with stretch therapy is frequently used in the treatment of my-ofascial pain syndrome [MPS]. Although rewarming is suggested after vapocoolant spray therapy,there have been no reports of its efficacy. We investigated the clinical efficacy of immediaterewarming after application of vapocoolant spray in patients with MPS.

Method: Female patients presenting with MPS in their upper trapezius muscle were included inthe study. Initial, pain intensity, lateral bending of the cervical spine, and pressure pain threshold[PPT] of the trigger points were assessed using a visual analog scale [VAS], measuring contralateralacromion–tragus distance, and a pressure algometer. Patients in the group one were treated withconventional spray with stretch; patients in the group two were treated with spray and stretch andrewarming with a moist hot pack. Therapies were carried out thrice each on three consecutive daysin both the groups.

Results: Eighty patients participated in the study. Both the groups showed statistically sig-nificant improvement in terms of pain, cervical range of motion [ROM], and PPT [p < 0.001].Improvements in VAS score and cervical ROM were significantly higher in the spray with stretchhot pack group than in the spray with stretch group. There was no significant difference betweenthe groups in terms of PPT [p < 0.05].

Conclusions: Adding rewarming to the spray with stretch therapy was more effective thanspray–stretch alone in reducing MPS symptoms. Rewarming using a moist hot pack should beincluded in conventional spray–stretch procedure in MPS treatment.

KEYWORDS. Myofascial pain syndrome, pain-pressure threshold, rewarming, spray withstretch, trapezius

Cengiz Bahadır, Vildan Yaman Dayan, Feride Ocak, and Semra Yigit, Physical Medicine and RehabilitationClinic, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey.

Address correspondence to: Cengiz Bahadır, MD, MS, Physiatrist, Physical Medicine and Rehabilitation Clinic,Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey. E-mail: delta2006@ttmail.com

Journal of Musculoskeletal Pain, Vol. 18(2), 2010Available online at www.informaworld.com/WJMP

© 2010 by Informa Healthcare USA, Inc. All rights reserved.doi: 10.3109/10582452.2010.483961 147

J M

usco

skel

etal

Pai

n D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

cgill

Uni

vers

ity o

n 10

/30/

14Fo

r pe

rson

al u

se o

nly.

148 JOURNAL OF MUSCULOSKELETAL PAIN

INTRODUCTION

Myofascial pain syndrome [MPS] is one ofthe most common causes of musculoskeletalpain. It is characterized by a palpable taut bandin a skeletal muscle and hyperirritable triggerpoints [TrPs] on this band (1). The pattern ofreferred pain and local twitch response [LTR]are important properties of TrPs. LTR can beobtained with snapping palpation or more com-monly with TrP needling (1). MPS symptomsinclude localized and referred TrP pain, auto-nomic effects, stiffness, and restricted range ofmotion [ROM].

The main goal of treatment is to break the vi-cious cycle of pain through elimination of TrPs.Spray with stretch, thermotherapy, cold therapy,dry needling of TrPs, injection of botulinumtoxin or local anesthetic, ultrasound, massage,ischemic compression, myofascial release tech-niques, iontophoresis, and transcutaneous elec-trical nerve stimulation are used solely or in com-bination (1–8).

Spray with stretch is among the most fre-quently used methods for treating MPS and canprovide immediate relief from pain (1). Usu-ally fluori-methane [mixture of flurocarbons,dichlorodifluoromethane, trichloromonofluoro-methane] and ethyl chloride are used as vapoc-oolants. These fluorocarbons cause seriousdegradation of the ozone layer and are thereforeno longer manufactured. However, a newly gen-erated, non-ozone depleting fluorocarbon mix-ture [pentafluoropropane, tetrafluoroethane] iscommercially available for medical usage. Ethylchloride is a toxic general anesthetic and hasbeen responsible for accidental deaths; it hasa low margin of safety and explodes when 4to 15 percent of its vapors are mixed with air(1).

Thermotherapy in the form of moist heathas been recommended for MPS treatment be-cause it tends to (1) increase local circulation,(2) relax underlying muscles, and (3) diminishthe tension on TrPs (1). Heat and cold thera-pies may be used in combination with othertherapies [e.g., massage, postisometric relax-ation, myofascial release] (1, 2). Travell (16)had advocated rewarming after spray–stretchtreatment and reapplication of spray, but con-trolled experiments on the effect of heat af-ter spray with stretch therapy have not beenreported.

We studied the efficacy of immediate applica-tion of superficial moist heat after conventionalspray–stretch therapy in MPS treatment.

MATERIALS AND METHODS

The study was in accordance with the HelsinkiDeclaration and was approved by institutionalethics committee, and informed consent was ob-tained from all the subjects.

Female patients presenting with acute or sub-acute stage unilateral MPS on the upper trapez-ius muscle were included. The MPS diagnosiswas made according to (1) a taut band on thepainful region of trapezius muscle, (2) a tenderTrP on this taut band, (3) reproduction of thelocalized and typical pattern of referred pain ofthe TrP in response to compression, and (4) ob-servation of LTR with snapping palpation of theTrP. A clinician with more than 10 years of ex-perience in MPS treatment identified TrPs viapalpation.

All patients were evaluated by the same physi-cian and sequentially randomized into one of thetwo study groups.

Exclusion criteria were as follows: (1) agemore than 50 years, (2) symptom duration formore than six months, (3) evidence of cer-vical disk disease, spondylosis, fibromyalgiasyndrome, inpingement syndrome, and othersoft-tissue disorders of the shoulder that maybe confused with MPS symptoms during clin-ical examination, (4) history of previous cer-vical trauma and surgery, and (5) anemia, in-creased level of uric acid, hypoglycemia, de-creased blood level of folic acid and vitaminB12, and thyroid function disorders that maycause resistance to specific MPS treatments incomplete blood screening, and any other sys-temic endocrine disease.

All patients were evaluated by the same physi-cian and consecutively assigned to one of the twostudy groups for randomization. All the subjectsunderwent the following procedures during theinitial evaluation: (1) symptom duration was de-termined, (2) TrPs were localized, (3) the levelof pain was assessed using a 10-grade visualanalog scale [VAS], (4) ROM for the active lat-eral flexion motion of neck, which was assessedby measuring the distance between contralat-eral acromion and tragus, and (5) pressure painthreshold [PPT] was measured using pressurealgometry.

J M

usco

skel

etal

Pai

n D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

cgill

Uni

vers

ity o

n 10

/30/

14Fo

r pe

rson

al u

se o

nly.

Bahadır et al. 149

Pressure algometry was done using a algome-ter [Algometer Commander, JTECH Medical,Salt Lake City, UT, USA]. The force recordedwas the amount of pressure that caused pain ordiscomfort [i.e., PPT]. A probe with a tip of1 cm2 was used for the measurement of PPTon the TrP. Pressure of approximately 1 kg/swas applied until it was perceived as discomfortor pain by the patient. Two consecutive mea-surements were taken at the intervals of 60 sec-ond. The mean values of two measurements wererecorded.

The same investigator in both the groupscarried out therapies. Patients were advised toavoid strenuous activity that may aggravate MPSsymptoms during the study.

Group 1, called the spray–stretch hot pack[SSH] group, received conventional spraywith stretch. Cryos spray [Phyto Performance,Padova, Italy], 400 milliliter, was applied as avapocoolant spray. The subject sat comfortablyand relaxed in a firm seat chair with the fingersof each hand hooked under the seat during theapplication. The investigator stretched the up-per trapezius muscle [with TrP] for maximumlengthening. Three superimposed spray sweepswere applied throughout the length of the uppertrapezius muscle and the region of referred painfor 30 second. Immediately after cessation ofthe spray sweeps, a hydrocollator hot pack wasapplied over the cold skin. Application of thehot pack and passive stretching were continuedfor 60 second in each therapy session. Group 2,called the spray–stretch [SS] group, received thesame spray with stretch therapy without appli-cation of the hot pack.

Therapy sessions were conducted thrice eachon three consecutive days in both the groups. As-sessments were made before the treatment and15 minutes after each session. The examiner whowas blinded to the investigation did this. To maskthe examiner to treatment assignment, treatmentand assessments were done in different roomsand the clinician who gave treatment directedeach subject not to discuss anything about thetreatment with the examiner.

Statistical Analyses

Statistical analyses were done using SPSS10.0 software. Parametric tests [paired sample

TABLE 1. Mean Age and Symptom Duration

Group Mean age [years]Mean duration ofsymptoms [days]

1 28.97 ± 6.75 63.80 ± 42.612 30.77 ± 7.93 50.02 ± 33.01

p = 0.39 p = 0.11

Values are mean ± standard deviation.

test, independent t-test] were used for the com-parison of results.

RESULTS

Eighty patients participated in the study; eachgroup consisted of 40 patients. The mean ageof patients was 29.87 ± 7.37 years [range: 18to 50 years]. There was no significant differ-ence between groups in terms of mean age andsymptom duration [Table 1]. There were no sta-tistically significant differences between groupsin initial VAS score, pain level, and PPT [p >0.05].

Statistically significant improvements werefound in pain level, ROM, and PPT in both thegroups [p < 0.001]. Comparing the improve-ments in VAS scores showed more statisticallysignificant improvement in the SSH group forall the assessments, but significant differenceswere only found in the first and the second as-sessments [p < 0.05] [Table 2]. Improvement incervical ROM was statistically significant for allthe assessments in the SSH group than in the SSgroup [p < 0.05] [Table 3].

There was no statistically significant differ-ence in PPT values in all the assessments [p >0.05; Table 4].

DISCUSSION

Almost all skeletal muscles could be affectedby MPS, and different methods have been usedfor treating patients with TrPs. Most studies onthe efficacy of the treatment methods have inves-tigated MPS of trapezius muscle (2–7). Trapez-ius muscle has been studied because it is (1)most affected by MPS, (2) readily stretched andevaluation is relatively easy compared to othermuscles (1), and (3) a reliable muscle in termsof the reproducibility of TrP pain and manual

J M

usco

skel

etal

Pai

n D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

cgill

Uni

vers

ity o

n 10

/30/

14Fo

r pe

rson

al u

se o

nly.

150 JOURNAL OF MUSCULOSKELETAL PAIN

TABLE 2. Visual Analog Scale Scores

VAS scores Pretreatment After first treatmentAfter second

treatment After third treatment

SSH Group P∗ 6.71 ± 1.93 2.90 ± 2.26 2.37 ± 2.09 2.0 ± 2.08[<0.001] [<0.001] [<0.001]

SS Group P∗ 6.47 ± 1.75 4.07 ± 2.14 3.45 ± 1.85 2.93 ± 2.59[<0.001] [<0.001] [<0.001]

p† 0.567 0.019 0.017 0.079

∗p value for comparison with pretreatment scores in both the groups.†p value for comparison of groups.VAS = visual analog scale, SSH = spray–stretch hot pack, SS = spray–stretch.Values are mean ± standard deviation.

identification of TrPs (9–11). Myburgh, Larsen,and Hartvigsen (11) have reported that themethodological quality of majority of the studiesfor the purpose of establishing TrP reproducibil-ity with manual palpation is generally poor.Gerwin, Shannon, Hong, Hubbard, and Gevirtz(9) showed that the reliability of recording dif-ferent features of TrPs varied between observers[LTR was most difficult to identify] so as theinter-observer reliability of identification of TrPfeatures between different muscles. Gerwin etal. also showed that a successful inter-observerreliability could be achieved with a training pro-gram for physicians after a failed test for inter-observer identification of TrPs with manual pal-pation. In the present study, the specific clinicalproperties of TrPs were in the inclusion crite-ria. An examiner experienced in MPS carriedout manual identification of TrPs as an initialexamination.

A pressure algometer can also be used foridentification of TrPs and measurement of TrPsensitivity (12–14). Delaney and McKee (13)

found high inter-observer versus intra-observerreliability for the measurement of TrP sensitivitywith a pressure algometer in trapezius muscle,and inferred that it could be useful for measur-ing and diagnosing MPS. The Sciotti study (11)revealed the internal validity of using a pressurealgometer on trapezius muscle.

The efficacy of vapocoolant spray therapy onMPS is well known, but recent studies havefailed to show its results (15–17). The effectsof fluorocarbons [destroying ozone layer] andethyl chloride [toxic effects] have contributedto their decreased usage. The present study, forthe first time, used a new vapocoolant spray [amixture of butane, isobutane, and propane] forMPS treatment. Travell (16) suggested rewarm-ing of skin after a specific cold spray with stretchtherapy. When used at the end of the treatment,the applied hot pack may leave the patient witha feeling of warmness and reassurance, whichfurther promotes reduction of muscle tensionby encouraging mental relaxation. No controlledstudy regarding efficacy of rewarming after cold

TABLE 3. Distance Between the Acromion and Tragus

Distance betweenthe acromion andtragus [cm] Pretreatment After first treatment

After secondtreatment After third treatment

SSH group P∗ 10.55 ± 1.11 9.17 ± 1.04 8.71 ± 0.89 8.47 ± 0.91[<0.001] [<0.001] [<0.001]

SS group P∗ 10.62 ± 1.15 9.76 ± 1.18 9.35 ± 1.26 8.97 ± 1.18[<0.001] [<0.001] [<0.001]

p† 0.769 0.021 0.011 0.039

∗p value for comparison with pretreatment scores in both the groups.†p value for comparison of groups.SSH = spray–stretch hot pack, SS = spray–stretch.Values are mean ± standard deviation.

J M

usco

skel

etal

Pai

n D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

cgill

Uni

vers

ity o

n 10

/30/

14Fo

r pe

rson

al u

se o

nly.

Bahadır et al. 151

TABLE 4. Pain Pressure Threshold

PPT [kg/cm2] Pretreatment After first treatmentAfter second

treatment After third treatment

SSH Group P∗ 2.73 ± 1.01 3.74 ± 1.01 4.07 ± 1.13 4.38 ± 1.17[<0.001] [<0.001] [<0.001]

SS Group P∗ 2.55 ± 0.92 3.89 ± 0.80 4.28 ± 0.85 4.59 ± 0.98[<0.001] [<0.001] [<0.001]

p† 0.417 0.453 0.348 0.402

∗p value for comparison with pretreatment scores in both the groups.†p value for comparison of groups.PPT = pain pressure threshold, SSH = spray–stretch hot pack, SS = spray–stretch.Values are mean ± standard deviation.

spray therapy has been reported. Furthermore,there are no precise suggestions regarding whenthe hot pack should be applied and how longit should be continued after spray therapy. Wechose to apply hot pack for rewarming immedi-ately after cold spray sweeps. The hot pack wasapplied just when the spray sweeps ceased andthe stretch continued. Stretch and hot-pack ap-plication were together continued for 60 second.This time was sufficient for skin temperature toreach normal and higher than the normal level.We preferred the hydrocollator hot pack becauseit is more effective than dry heat in MPS (1).

The SS and SSH therapy sessions were foundeffective in reducing ROM limitation and thepain and sensitivity of TrPs. Improvements inVAS score and ROM were more significant inthe SSH group than in the SS group. Althoughdifferences in terminal VAS scores were foundto be statistically insignificant, SSH provided aquicker recovery time. The SSH group had aslightly higher initial mean VAS score, but theVAS score on day 1 was lower than the VASscore in the SS group achieved on day 3. Similarquick therapeutic onset was also seen in ROMvalues in the SSH group. The increase in ROMmay have been caused by an increase in mus-cle temperature due to hot-pack application. Butconsidering the duration of hot-pack application,i.e., 60 second, this time was not sufficient toincrease muscle temperature, which may causedirect elongation of muscle length. This findingsuggests that increase in ROM may be related toindirect mechanisms.

Mean increase in PPT was more prominentin the SS group; however, the difference wasnot significant. Pain–pressure threshold mayhave been expected to be higher due to the

well-known local anesthetic effect of superficialcold. This effect was offset by measurementsmade 15 minutes after each therapy session,when the cold effect of the spray had stopped. Webelieve this provided more reliable PPT compar-ison between groups. Hou, Tsai, Cheng, Chung,and Hong (2) showed that the efficacy of com-bination therapies with spray–stretch reducedMPS symptoms in trapezius muscle and furtherrevealed that a significant increase in PPT ofTrPs could be obtained with these combinationtherapies. In the same study, spray with stretchtherapy was combined with hot-pack and activeROM exercises, but application details were notprovided (2).

Patients with symptoms for more than sixmonths were not included in our study. Treat-ment of chronic MPS is much more difficultthan acute and subacute MPS. So our findingsmay not demonstrate the efficacy of immedi-ate rewarming after stretch and spray in pa-tients with chronic myofascial pain syndromes.Additionally, male patients were not includedin our study. Our results have shown the pos-itive effects of rewarming after conventionalstretch and spray only in women with MPS.These should be noted as a limitation of thisstudy.

The effect mechanism of stretch and sprayhas not been investigated sufficiently. Simons,Travell, and Simons (1) have proposed that tac-tile stimulation caused by sudden cold and thevapocoolant stream over the skin causes a con-tinuous blockage of alarming impulses to thespinal cord. This input has an inhibitory effecton locally generated pain from TrPs. The auto-nomic nervous system can influence the inten-sity of activity of TrP mechanism at the motor

J M

usco

skel

etal

Pai

n D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

cgill

Uni

vers

ity o

n 10

/30/

14Fo

r pe

rson

al u

se o

nly.

152 JOURNAL OF MUSCULOSKELETAL PAIN

endplate (18). Simons et al. also proposed thatthe spray effect on the skin could inhibit thisautonomic activation at the spinal cord level(18, 19). A recent study by Kostopoulos andRizopoulos (20) investigated the effect of sprayand stretch by comparing it with stretch alone forhip flexion on healthy individuals. They showedthat more hip flexion gains could be achievedwith stretch and spray techniques. They reportedthat stretch and spray technique seems to haveneurophysiological effect that involves suddendecrease in skin temperature affecting intrafusalmuscle fibers that control muscle tension. Var-ious mechanisms may have played part in thesuperior effect of adding hot packs to conven-tional spray with stretch therapy. It can be hy-pothesized that application of a hot pack overcold skin may create a secondary inhibitory ef-fect in the medulla spinalis by using identicalpathways.

Adding rewarming to the conventional spraywith stretch therapy was more effective thanspray–stretch alone in reducing MPS symptoms.Consecutive application of spray and hot packmay be an alternative treatment for MPS andprovide quicker recovery.

Declaration of interest: The author reports noconflict of interest. The author alone is respon-sible for the content and writing of this paper.

REFERENCES

1. Simons DG, Travell JG, Simons LS: MyofascialPain and Dysfunction: The Trigger Point Manual. Lip-pincott Williams & Wilkins, Philadelphia, PA, 1999, pp.94–177.

2. Hou CR, Tsai LC, Cheng KF, Chung KC, HongCZ: Immediate effects of various physical therapeuticmodalities on cervical myofascial pain and trigger-pointsensitivity. Arch Phys Med Rehabil 83: 1406–1414,2002.

3. Esenyel M, Caglar N, Aldemir T: Treatment ofmyofascial pain. Am J Phys Med Rehabil 79: 48–52,2000.

4. Gemmelll H, Miller P, Nordstrom H: Immediateeffect of ischaemic compression and trigger point pres-sure release on neck pain and upper trapezius triggerpoints: A randomised controlled trial. Clin Chiropractic11: 30–36, 2008.

5. Hong CZ: Lidocaine injection versus dry needlingto myofascial trigger point. The importance of the localtwitch response. Am J Phys Med Rehabil 73: 256–263,1994.

6. Hsueh TC, Cheng PT, Kuan TS, Hong CZ: Theimmediate effectiveness of electrical nerve stimulationand electrical muscle stimulation on myofascial trig-ger points. Am J Phys Med Rehabil 76: 471–476,1997.

7. Majlesi J, Unalan H: High-power pain thresholdultrasound technique in the treatment of active myofas-cial trigger points: A randomized, double-blind, case-control study. Arch Phys Med Reahabil 85: 833–836,2004.

8. Rubin D: Myofascial trigger point syndromes: Anapproach to management. Arch Phys Med Rehabil 62:107–110, 1981.

9. Gerwin RD, Shannon S, Hong CZ, Hubbard D,Gevirtz R: Interrater reliability in myofascial triggerpoint examination. Pain 69: 65–73, 1997.

10. Sciotti VM, Mittak VL, DiMarco L, Ford LM,Plezbert J, Santipadri E, et al.: Clinical precision ofmyofascial trigger point location in the trapezius muscle.Pain 93: 259–266, 2001.

11. Myburgh C, Larsen AH, Hartvigsen J: A system-atic, critical review of manual palpation for identifyingmyofascial trigger points: Evidence and clinical signif-icance. Arch Phys Med Rehabil 89: 1169–1176, 2008.

12. Delaney GA, McKee AC: Inter- and intra-rater re-liability of the pressure threshold meter in measurementof myofascial trigger point sensitivity. Am J Phys MedRehabil 72: 136–139, 1993.

13. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S,Zengin FO, Bayik Y: Comparison of lidocaine injection,botulinum toxin injection, and dry needling to triggerpoints in myofascial pain syndrome. Rheumatol Int 25:604–611, 2005.

14. Silva RS, Conti PC, Lauris JR, da Silva RO, Pe-goraro LF: Pressure pain threshold in the detection ofmasticatory myofascial pain: An algometer-based study.J Orofac Pain 19: 318–324, 2005.

15. Mennel J: Spray-stretch for relief of pain frommuscle spasm and myofascial trigger points. J Am Po-diatry Assoc 66: 873–876, 1976.

16. Travell J: Ethyl chlorides spray for painful musclespasm. Arch Phys Med Rehabil 33: 291–298, 1952.

17. Garvey TA, Marks MR, Wiesel SW: A prospec-tive, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine 14:962–964, 1989.

18. Simons DG, Travell JG, Simons LS: MyofascialPain and Dysfunction: The Trigger Point Manual. Lip-pincott Williams & Wilkins, Philadelphia, PA, 1999, pp.11–93.

19. Simons DG, Mense S: Diagnosis and therapy ofmyofascial trigger points. Schmerz 17: 419–424, 2003.

20. Kostopoulos D, Rizopoulos K: Effect of topicalaerosol skin refrigerant (spray and stretch technique) onpassive and active stretching. J Bodyw Mov Ther 12:96–104, 2008.

Submitted: January 12, 2009Revision Accepted: May 29, 2009

J M

usco

skel

etal

Pai

n D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

cgill

Uni

vers

ity o

n 10

/30/

14Fo

r pe

rson

al u

se o

nly.