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Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis

Rathbone, Alasdair T.L. H. BSc. Kin.*,†; Grosman-Rimon, Liza PhD†,‡; Kumbhare, Dinesh A. MD, MSc, FRCP(C), DABPMR†,‡

doi: 10.1097/AJP.0000000000000459
Original Articles

Objective: To achieve a statistical estimate of the agreement of manual palpation for identification of myofascial trigger points (MTrPs) and secondarily to investigate potential factors impacting the agreement of this technique.

Methods: We searched MEDLINE(R) and Embase for studies examining the reproducibility of manual palpation for the identification of MTrPs from the year 2007 to present. In addition, we utilized studies identified by 2 comprehensive systematic reviews that covered the period before 2007. The included studies were original peer-reviewed research articles and included Cohen κ measures or data with which to calculate Cohen κ. Studies were excluded if they lacked a measure of variability or information required to calculate variability. Studies that examined palpation through body cavities were also excluded. Of the 18 potentially relevant articles only 6 met inclusion criteria including 363 patients. Modified QUADAS tool was used to assess study validity. Subgroup comparisons were made utilizing Q and Z tests.

Results: An estimate of κ=0.452 (95% confidence interval, 0.364-0.540) was obtained for interrater agreement of manual palpation of MTrPs. Localized tenderness (κ=0.676) and pain recognition (κ=0.575) were the most reliable criteria. Only 1 study met inclusion criteria for intrarater agreement and therefore no meta-analysis was performed.

Discussion: Use of manual palpation for identification of MTrPs is unreliable, and future investigation should focus on integration with more reliable techniques.

*Schulich School of Medicine and Dentistry, University of Western Ontario, London

Toronto Rehabilitation Institute, Musculoskeletal Rehabilitation Program, University Health Network (UHN)

Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada

Work completed at Toronto Rehabilitation Institute.

The authors declare no conflict of interest.

Reprints: Dinesh A. Kumbhare, MD, MSc, FRCP(C), DABPMR, Toronto Rehabilitation Institute, Musculoskeletal Rehabilitation Program, University Health Network (UHN), 550 University Avenue Toronto, ON, Canada M5G 2A2 (e-mail:

Received July 16, 2015

Received in revised form January 31, 2017

Accepted November 9, 2016

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