Journal of Bodywork & Movement Therapies (2017) 21, 11e18

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REPEATED MEASUREMENTS STUDY

Effect of exams period on prevalence of

Myofascial Trigger points and head posture
in undergraduate students: Repeated
measurements study
Leonid Kalichman, PT, PhD*, Natalie Bulanov, BPT,
Aryeh Friedman, BPT

Physical Therapy Department, Recanati School for Community Health Professions, Faculty of Health
Sciences at Ben-Gurion University of the Negev, Beer Sheva, Israel

Received 23 November 2015; received in revised form 14 March 2016; accepted 21 March 2016

KEYWORDS Summary Background: Myofascial Trigger points (MTrPs) may be caused or aggravated by
Myofascial trigger many factors, such as mental stress associated with exams and impaired posture.
points; Aim: To compare the prevalence and sensitivity of MTrPs, and forward head position (FHP) dur-
Forward head ing exam period vs. mid-semester among physical therapy students.
position; Methods: 39 physical therapy students were palpated for MTrPs in neck and shoulder muscles
Exams and were photographed laterally for FHP measurement during the academic semester and dur-
ing the academic examination period.
Results: The subjects showed higher prevalence of active MTrPs in the right Trapezius and Le-
vator Scapula muscles, and higher prevalence of latent MTrPs in the left Sternocleidomastoi-
deus and Levator Scapula muscles during exams, as well as a higher rate of tenderness in
suboccipital musculature.
Conclusions: Physical therapy students show greater prevalence of MTrPs during exams. The
authors recommend implementing preventative programs towards the examination period.
2016 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences,
Ben-Gurion University of the Negev, POB 653, Beer Sheva, 84105, Israel. Tel.: 972 52 2767050; fax: 972 8 6477683.
E-mail addresses: kalichman@hotmail.com, kleonid@bgu.ac.il (L. Kalichman).

http://dx.doi.org/10.1016/j.jbmt.2016.04.003
1360-8592/ 2016 Elsevier Ltd. All rights reserved.
12
Background
Myofascial trigger points (MTrPs) are a widely prevalent
phenomenon that has been studied extensively in recent
years (Tali et al., 2014). Travell and Simons (1983e1992)
defined MTrPs as a hyperirritable spot, usually within a
taut band of skeletal muscle or in the muscles fascia, that
is painful on compression and that can give rise to char-
acteristic referred pain, tenderness and autonomic phe-
nomena (the hyperirritable spot is often within a palpable
nodule) (Travell & Simons, 1983e1992). The pathophysi-
ology of MTrPs is not completely understood. A common
agreement is that muscle overload or direct trauma to the
muscle might lead to the development of MTrPs (Bron and
Dommerholt, 2012). The most hypothesized theory today
is that the MTrPs are areas of sensitized low-threshold
nociceptors (free nerve endings) combined with motor
endplate dysfunction and possibly an increased leakage of
acetylcholine (Huguenin, 2004; Kuan et al., 2007; Hong and
Simons, 1998). Electrophysiological studies have demon-
strated abnormal electrical activity near MTrPs, which is
described in literature as endplate noise, and is associated
with an increased amount of acetylcholine. This amount is
not sufficient to create a muscle contraction, but might
explain the taut band and the nodule in the muscle
(Huguenin, 2004).
MTrPs are divided into two major sub-categories: active
and latent. Active MTrPs are associated with spontaneous
local and referred pain. They may also be associated with
other symptoms such as weakness, paresthesia, or tem-
perature changes, whereas latent MTrPs only evoke local or
referred pain when palpated and direct pressure is applied
to them (Travell & Simons, 1983e1992). Latent MTrPs may
become activated by a variety of stimuli, including poor
posture, overuse, or muscle imbalance (Travell & Simons,
1983e1992, Huguenin, 2004). However, both active and
latent MTrPs cause loss of range of motion and weakness,
which can result in limited function (Travell & Simons,
1983e1992). Shah et al. (2005) and Bron and Dommerholt
(2012) showed that there are differences in the biochem-
ical concentration in the areas near active MTrPs compared
to latent MTrPs. Biochemicals associated with pain and
inflammation such as bradykinin, substance P, interleukins,
norepinephrine and more, were significantly higher near
active MTrPs and the pH levels found near active MTrPs
were significantly lower.
Studies have shown that MTrPs are often the cause of
symptoms among patients whose primary complaint is pain.
One study found that 30% of general internal medicine
patients suffering from undiagnosed pain suffered from
active MTrPs (Skootsky et al., 1989), while another study
found MTrPs to be the cause of head and neck pain in 55.4%
of the patients examined (Fricton et al., 1985).
According to Gerwin et al. (1997), there are a variety of
clinical characteristics that indicate the presence of a
MTrP, the most prominent being: a tender point in a taut
band of muscle, a local twitch response (LTR) to mechani-
cal stimulation, a pain referral pattern characteristic of
MTrPs of specific areas in each muscle, and the reproduc-
tion of the patients usual pain (Gerwin et al., 1997).
Myburgh et al. (2011) suggested the diagnosis should be a
L. Kalichman et al.
global assessment-either the MTrP is present, or it is not. He
based this idea on Brunse et al. (2010) diagnosis of
musculoskeletal chest pain. In order to positively diagnose
an MTrP, at least two of the four aforementioned criteria
must be present, with the presence of a taut band neces-
sary for a positive diagnosis (Myburgh et al., 2011).
Studies suggest that myofascial pain may be triggered,
among other causes, by mental stress. It is also assumed
that stress and anxiety influence pain. In a study conducted
by Vedolin et al. (2009), the stress and anxiety levels were
shown to be higher as the academic exam period
approached, both in healthy subjects and in patients with
chronic temporomandibular joint pain, though the tempo-
romandibular joint patients reported higher stress levels
than the healthy subjects. When pressure pain threshold
(PPT) was measured, PPT values were lower in both groups
during the examination period. A different study showed
similar results: The PPTs of the masticatory muscles and the
Achilles tendon were significantly lower in stressed stu-
dents, on the exam day and the adjacent days (Michelotti
et al., 2000). Treaster et al. (2006) investigated the
development of MTrPs during computer work, and
concluded that the visual stress caused during computer
work increases the formation of MTrPs, especially in the
trapezius muscles.
In Moraskas (Moraska and Chandler, 2009) work, an as-
sociation between stress and MTrPs is presented through a
massage therapy aimed for MTrPs, which resulted in
reduced levels of anxiety, depression and overall stress
levels.
Many studies have established an association between
MTrPs and headaches such as Tension Type Headaches
(TTH) and Migraine Headaches (Davidoff, 1998). A connec-
tion has also been shown between the presence of active
MTrPs and a greater intensity and longer duration of
headache episode (Fernandez-de-Las-Penas et al., 2006a,
b). The research group of Fernandez de las Penas
(Fernandez-de-Las-Penas et al., 2006a, b, c, d; Fernandez-
de-Las-Penas et al., 2007; Fernandez-de-Las-Penas et al.,
2010) has conducted numerous studies regarding MTrPs in
cervical muscles and different types of headaches. In one
study, authors demonstrated that both active MTrPs in the
suboccipital muscles and forward head position (FHP)
correlate with chronic TTH (Fernandez-de-las-Penas et al.,
2006b). In another study, he established a correspondence
between active MTrPs and migraine headaches (Fernandez-
de-Las-Penas et al., 2006d). In both studies the majority of
MTrPs among the study groups were active, and all subjects
in the study group without active MTrPs presented latent
MTrPs (Fernandez-de-las-Penas et al., 2006b, d).
FHP is a common postural disorder, in which the cra-
niovertebral angle indicates the head on trunk positioning.
A small angle often appears with shortening of the cervical
extensors as well as the sternocleidomastoid (SCM)
(Grimmer-Somers et al., 2008; Fernandez-de-las-Penas
et al., 2006b). In Fernandez-de-las-Penas et al. (2006b)
study regarding FHP and TTH, the craniovertebral angle
was compared between a group of chronic TTH patients and
matched controls. Within the chronic TTH group, the cra-
niovertebral angle was smaller, and headache frequency
and duration was significantly higher (Fernandez-de-las-
Penas et al., 2006b). In a cross-sectional study of 62
Effect of exams on prevalence of trigger points and head posture
subjects with neck pain and 52 healthy subjects, a signifi-
cantly smaller craniovertebral angle was found in the neck
pain group. Moreover, the subjects with smaller cranio-
vertebral angle scored higher in Northwick Park Neck Pain
Questionnaire and Numeric Pain Rating Scale. These results
demonstrate that the severity of the FHP correlates with
functional disabilities and neck pain (Yip et al., 2008).
Another study showed that as the FHP severity increases, a
decrease in cervical joint position sense was found,
implying a connection between FHP and proprioception
(Lee et al., 2014).
University students preparing for exams are exposed to a
wide variety of predisposing factors for MTrPs, mainly
prolonged sitting, prolonged use of computers, mental
concentration, reading papers, and psychological stress
which can result in FHP and MTrPs (Treaster et al., 2006;
Hoyle et al., 2011). Shahidi et al. (2013) demonstrated
that circumstances that require high mental concentration
correlate with high stress levels and high trapezius muscle
activity. The same study also showed that the FHP became
worse during mental concentration (Shahidi et al., 2013).
The aim of the study was to compare the prevalence and
sensitivity of MTrPs and forward head position (FHP) during
exam period vs. mid-semester in physical therapy students.
Methods
Design
Repeated measurements study with no intervention.
Setting
Department of Physical Therapy, Recanati School for
Community Health Professions, Faculty of Health Sciences,
Ben Gurion University of the Negev, Beer Sheva, Israel.
Sample
41 students were recruited for the study, of which 39 stu-
dents participated in both measurements and two only in
the first measurement. Participation was voluntary and
students were not compensated for their time.
Inclusion criteria
physical therapy students, males and females, 20e30 years
old.
Exclusion criteria
significant neck or head injury in the past three years;
active neurological disorder; mental disorders; significant
scoliosis or kyphosis.
Data collection
Basic demographic data were collected using a self-
administered questionnaire and include age, sex, self-
reported weight and height (from which Body Mass Index
13
(BMI) was calculated as weight in kg divided by height in
meters squared) and smoking.
Measurements
Each subject was examined twice: once during the semes-
ter, then again during the exams period, or vice versa.
About alf of the sample (N Z 20) was evaluated first time
during the semester and second time during the exams
period, another half (N Z 19) were evaluated in an oposit
order. Examiners during the second evaluation were blin-
ded to the results of the first examination. Before each
measurement the subjects filled in a subjective numeric
rating scale (NRS) evaluating stress level, head and neck
pain, as well as a widely used 14 item Perceived Stress Scale
(PSS) questionnaire. The Alpha Cronbach reliability of the
Hebrew version is 79 (Cohen et al., 1983). The examination
included assessment of MTrPs in the cervical musculature
and tenderness of the suboccipital muscles, while testing
the PPT in the MTrPs discovered.
Outcome measures
FHP evaluation
FHP is defined by the angle between the line connecting the
two markers and a horizontal line drawn from the cervical
marker. A computer program (MB Ruler) was used to
calculate the angle. This is the most common method for
sagittal plane posture assessment today, and it has also
been suggested that due to the natural postural sway it is
more reliable to measure the angle while sitting, rather
than upright (Grimmer-Somers et al., 2008). FHP was
examined through a lateral photograph, with one marker
placed on the tragus of the left ear and one on the spinous
process of C7 vertebra (Grimmer-Somers et al., 2008).
MTrP evaluation
MTrP diagnosis relies mainly on manual evaluation due to
lack of established reliable imaging or laboratory tech-
niques. There is no gold standard for diagnosis of MTrPs to
which manual palpation can be compared (Bron et al.,
2007; Huguenin, 2004). Wytra _
zek et al. (2015) study
aimed to correlate palpatory findings with algometric
measurements and surface electromyography (sEMG) re-
cordings in neck and shoulder girdle muscles. Seventy vol-
unteers were palpated bilaterally in four different shoulder
muscles, and were examined by sEMG. The study showed
that palpation findings correspond with sEMG recordings
and algometry measurements, which lead to a conclusion
that palpation may be regarded as an objective instru-
mental method.
Before the beginning of the current study, both exam-
iners (senior year physical therapy students A.F. and N.B.)
underwent training in finding MTrPs, led by an experienced
instructor in myofascial pain evaluation and treatment
(L.K.). During the training, they practiced palpation skills,
rehearsed the surface anatomy of relevant areas, discussed
technique, amount of pressure and subjects position and
prepared a detailed protocol of MTrPs evaluation.
The Upper Trapezius, Levator Scapula, and SCM muscles
were examined bilaterally for MTrPs. Two examiners who
14
classified the results as active MTrP, latent MTrP, tight
band, or no MTrP performed the examination separately. To
define an MTrP, the examiners palpated the muscles in
search of a taut band in the muscle, within which they
looked for a nodule. If a nodule was located, the examiner
pressed the nodule for few seconds and asked the subject
whether it evoked pain. If the subject responded nega-
tively, the findings were described as a taut band. If the
subject responded positively, he/she was asked to show
where pain was felt and whether the pain is familiar. A
referred and familiar pain was considered an active MTrP,
while local or referred but unfamiliar pain was considered a
latent MTrP.
For Upper Trapezius and SCM muscles the examiners
used a pincer palpation technique, as suggested by Travell
and Simons (1983e1992), to find a hyperirritable spot or
nodule and press it against the muscle fibers. For the Le-
vator Scapula examiners used a flat palpation technique at
the muscles insertion to find a hyperirritable spot and
press it toward the underlying bone (Travell & Simons,
1983e1992). Only consistent diagnoses between exam-
iners were regarded as MTrPs.
Once a positive diagnosis was achieved, the MTrP
sensitivity was tested by one of the examiners by measuring
the PPT with an algometer. If multiple MTrPs were found in
the same muscle, the examiner asked the subject to indi-
cate the most irritable spot. The examiner instructed the
subject as following: I am going to apply pressure, tell me
when you feel a minimal amount of pain (in Hebrew), then
applied pressure to the MTrP with the algometer, at a rate
of approximately 1 kg/cm2/second. This method has been
shown to have high interrater and intra-rater reliability by
Reeves et al. (1986).
Suboccipital muscle tenderness
The suboccipital muscles were palpated by both examiners
and the subjects were requested to report pain if it was
evoked. This criteria was measured dichotomously-pain was
either present or absent.
Ethical considerations
Participation in the study was voluntary. Each subject
received an explanation as to the aims of the study and
methods of data and signed an informed consent form. The
study was approved by the Ethics Committee of the Reca-
nati School for Community Health Professions.
Statistical analysis
All statistical computations were performed using the SPSS
17.0 for Windows (SPSS, Chicago, IL, USA). Statistical ana-
lyses were conducted at a 95% confidence level. A p-value
<0.05 was considered significant.
Descriptive statistics were used to characterize the
sample. To compare continuous variables (FHP, NRS stress
level and PSS, NRS headache and neck pain, and PPTs of all
studied muscles) measured during the semester vs. ones
measured during the exams period we used paired T-test.
To compare (semester vs. exams) suboccipital muscles
tenderness, as well as prevalence of latent and active
MTrPs (dichotomous variables) Wilcoxon Signed Ranks Test
was used. We also conducted the same test separately in
two sub-samples, those that evaluated first during the
L. Kalichman et al.
semester and those evaluated first during the exams
period.
In addition, the results of the muscles palpation findings
were ranked as ordinal variables (0-no findings, 1-tight
band, 2-latent MTrP and 3-active MTrP). These findings
were compared (semester vs. exams) using Wilcoxon Signed
Ranks Test.
Results
In this study 39 students from the physical therapy
department were analyzed (Table 1). Average age:
25.33  1.94, 30 (76.9%) of which were female. Students
were recruited from three different classes: 11 (28.2%) first
year students, 8 (20.5%) second year, and 20 (51.3%) third
year students. BMI was calculated based on self-reported
height and weight. Mean BMI (kg/m2): 22.80  3.07
(17.80e30.86). Regular physical activity was reported by 35
(89.7%) students, with a mean duration (hours/week)
4.24  2.60 (0e10).
Subjective self-reported NRS stress level was signifi-
cantly higher during exams, scored6.21  2.20, compared
to 3.72  2.61 during the semester (p < 0.001). This is
consistent with the PSS scores, which are also significantly
higher during the exams: 2.21  0.42, compared to
1.99  0.37 during the semester (t Z 3.174, p Z 0.003).
FHP showed no significant difference between the se-
mester and the exams period. The mean CV angle measured
during semester was 48.82  5.30, and examination period
mean angle was 49.58  6.35.
In all studied muscles the PPT was higher during exam-
ination (Table 2). However, only three muscles had statis-
tically significant differences: Right SCM, Left SCM and
Right Levator Scapula. Subjective headache and neck pain
NRS was also significantly higher during examination period:
Headache NRS during the semester: 1.62  2.42, during
exams: 2.87  2.82 (t Z 2.698, p Z 0.01). Neck pain NRS
during the semester: 1.90  2.30, during exams:
3.05  2.47 (t Z 3.283, p Z 0.002).
Active MTrPs in the Right Trapzius and Right Levator
scapula muscles were significantly more prevalent during
the exams (p Z 0.035 and 0.014, correspondingly), as well
Table 1 Characteristics of subjects (n Z 39).
Characteristics n (%) Mean  SD (minemax)
Age (years) 25.33  1.94 (22e30)
Gender (females) 30 (76.9)
BMI (kg/m2) 22.80  3.07
(17.80e30.86)
Year at university
1st 11 (28.2)
2nd 8 (20.5)
3rd 20 (51.3)
Leisure physical activity
Participation 35 (89.7)
Duration (hours/week) 4.24  2.60 (0e10)
Smoking 5 (12.8)
Handedness (right) 35 (89.7)
BMI e body mass index; SD e standard deviation.
Effect of exams on prevalence of trigger points and head posture 15

Table 2 The comparison between continuous measurements done during the semester and ones during exams.
Variables During semester During exams Comparison
Mean SD Mean SD t Sig. (2-tailed)
FHP 48.82 5.30 49.58 6.35 1.266 0.213
NRS stress level 3.72 2.61 6.21 2.20 5.787 0.000
PSS 1.99 0.37 2.21 0.42 3.174 0.003
NRS headache 1.62 2.42 2.87 2.82 2.698 0.010
NRS neck pain 1.90 2.30 3.05 2.47 3.283 0.002
PPT Right Trapezius 1.55 0.78 1.56 0.64 0.092 0.927
PPT Left Trapezius 1.76 0.73 1.84 0.91 0.443 0.660
PPT Right SCM 0.29 0.51 0.63 0.59 2.982 0.006
PPT Left SCM 0.19 0.44 0.52 0.62 2.553 0.016
PPT Right Levator Scapula 1.28 1.13 1.77 0.98 2.379 0.023
PPT Left Levator Scapula 1.09 0.99 1.48 0.96 1.878 0.068
FHP e forward head posture; SD e standard deviation; Sig. e significance; NRS e numeric rating scale; PPT e pressure pain threshold;
SCM e sternocleidomastoid muscle.
Statistically significant differences (p < 0.05) marked bold.

as latent MTrPs in the Left SCM and Left Levator Scapula
muscles (p Z 0.007 and 0.029, correspondingly). Sub-
occipital muscle tenderness was also significantly more
prevalent during the exams (p Z 0.011). In the other
muscles examined, no significant results were demon-
strated (Table 3). The total prevalance of MTrPs, both
active and latent, during the exam period was higher
compared to the semester.
When treated as a ordinal variables, myofascial findings
showed significantly higher prevalence of MTrPs in the right
Trapezius and right SCM muscles during exams (Table 4).
We calculated the power (probability) to reject the null
hypothesis that this response difference between semester
and exam period is zero for the following parameters:
N Z 39, type I probability Z 0.05. For all parametric tests
the power was <0.8, meaning that our sample size was
sufficient to test our hypotheses.
Discussion
The results of this study showed a greater prevalance of
MTrPs during the exam period, in correlation with the
studys thesis. Many studies have established a connection
between mental load and muscle activity, as Roman-Liu
et al. (2013) discuss in depth in the introduction to their
study. The results of their study confirm that muscle ten-
sion increases during sustained attention and vigilance
tests, especially in the shoulder girdle and, less signifi-
cantly, in the forearm (Roman-Liu et al., 2013). The re-
searchers attempted to isolate the mental load from
posture by having the study and control groups remain in
the same supported posture throughout the test, thus
minimizing the biomechanical load on the shoulder girdle.
Shahidi et al. (2013) study also showed an increase in
muscle EMG activity during high stress condition in

Table 3 The comparison between measurements done during the semester and ones during exams.
Variables During semester During exams Comparison
Yes No Yes No Za Sig. (2-tailed)
Suboccipital muscles tenderness 27 14 33 6 2.530 0.011
Active MTrPs Right Trapezius 11 30 17 22 2.111 0.035
Active MTrPs Left Trapezius 7 34 9 30 1.000 0.317
Active MTrPs Right SCM 3 38 4 35 0.447 0.655
Active MTrPs Left SCM 3 38 2 37 1.000 0.317
Active MTrPs Right Levator Scapula 2 39 7 32 2.449 0.014
Active MTrPs Left Levator Scapula 5 36 2 37 1.342 0.180
Latent MTrPs Right Trapezius 28 13 21 18 1.508 0.132
Latent MTrPs Left Trapezius 34 7 29 10 1.342 0.180
Latent MTrPs Right SCM 6 35 13 26 1.941 0.052
Latent MTrPs Left SCM 2 39 11 28 2.714 0.007
Latent MTrPs Right Levator Scapula 25 15 24 15 0.277 0.782
Latent MTrPs Left Levator Scapula 21 20 29 10 2.183 0.029
Statistically significant differences (p < 0.05) marked bold.
a
Result of the Wilcoxon Signed Ranks Test; Sig. e significance; SCM e sternocleidomastoid muscle.
16 L. Kalichman et al.

Table 4 Comparison between muscles palpation findings done during the semester and ones during exams (MTrPs findings
treated as ordinal variable).
Variables MTrPs evaluation Comparison
No Tight band Latent MTrPs Active MTrPs Za Sig. (2-tailed)
Right Trapezius Semester 1 1 28 11 2.111 0.035
Exams 1 0 21 17
Right SCM Semester 25 7 6 3 1.975 0.048
Exams 18 4 13 4
Right Levator Scapula Semester 13 0 26 2 1.811 0.070
Exams 8 0 24 7
Left Trapezius Semester 0 0 34 7 0.000 1.000
Exams 1 0 29 9
Left SCM Semester 31 4 3 3 1.762 0.078
Exams 21 5 11 2
Left Levator Scapula Semester 15 0 21 5 1.232 0.218
Exams 8 0 29 1
Statistically significant differences (p < 0.05) marked bold.
a
Result of the Wilcoxon Signed Ranks Test; Sig. e significance; SCM e sternocleidomastoid muscle.

comparison to low stress, in the Upper Trapezius muscle,
both in dominant and non-dominant sides.
In Linton (2000) review of 11 studies discussing stress
and anxiety, a significant relation was found between these
parameters and neck or back pain. This is consistent with
the current studys results, in which the NRS of neck pain
was significantly higher during the exam period.
The hypothesis that FHP will be more pronounced during
the exam period was repudiated. The FHP was slightly lesser
during the semester with the mean angle measuring a mere
0.76 degrees less than the mean angle during the exam
period. This could be explained by Shahidi et al. (2013)
study, in which subjects had to complete a computer task
in low stress and in high stress conditions. the CV angle
measured during the task was smaller compared to baseline
measurements, but there was no difference between the
lower and the higher stress conditions. In other words, the
CV angle decreases during task performance and mental
concentration but is not necessarily influenced by stress
levels. Based on these findings, it is possible that because
students require mental concentration during the semester
as well as during exams, the FHP results are similar during
the two time periods, despite the difference in stress levels.
The PPT values in the current study were consistently
higher during examinations than during the semester, con-
trary to the researchers hypothesis and to other studies: In
one study, the researchers asserted that fear and anxiety
affect the pain threshold inversely: While fear decreases
pain and increases PPT values, anxiety decreases the PPT
and increases pain sensitivity (Rhudy and Meagher, 2000).
According to their definition of anxiety, future-oriented
emotion characterized by negative affect and apprehensive
anticipation of potential threats (Rhudy and Meagher,
2000). It would seem that students during exams fall into
that category, yet their results differ from the results of the
current study. Vedolin et al. (2009) and Michelotti et al.
(2000) also conducted studies with results that disagree
with the findings of the current study. Both studies found
the academic examination to be a natural stressor, and
investigated the influence of stress and anxiety on the PPT.
The findings of these studies were a drop in the PPT values,
suggesting the stress condition increases the pain sensi-
tivity. However, in Michelotti et al. (2000) study it is stated
that the spearman correlation between changes in PPT and
stress, on the day of exam and a month later, were
generally low.
It is possible that the current study is less reliable than
contradicting studies, as the PPT was measured only once
at each location in the current study, whereas most other
studies involved multiple measurements with a mean or
maximal result (Michelotti et al., 2000; Walton et al., 2014;
Chesterton et al., 2003; Vedolin et al., 2009). On the other
hand, the consistent increase in PPT during exams (in both
sub-samples, those that evaluated first during the semester
and those evaluated first during the exams period) and the
statistically significant values of the current study suggest
low risk of bias in PPT evaluations.
In the current study, suboccipital tenderness was
examined as an indication of possible MTrPs in the sub-
occipital muscles. Travell and Simons (1983e1992) wrote
that actual diagnosis of MTrPs in these muscles is very
difficult, given the layers of muscles superficial to them.
Fernandez-de-las-Penas et al. (2006b) devised an inter-
esting method which defined modified criteria for diag-
nosis: the suboccipital muscles are to be palpated and
compressed for 10 s with the neck in neutral position while
the subject is supine. If the aforementioned palpation
elicits pain, the subject should be instructed to extend his
upper cervical spine by tilting his head back. If this exam-
ination elicits familiar pain, the MTrP is defined as active. If
the elicited pain is unfamiliar, The MTrP is be defined as
inactive (Fernandez-de-las-Penas et al., 2006b). Regret-
tably, this method has not been validated and was there-
fore deemed irrelevant to the current study. If this method
will be validated, it could be a valuable diagnostic tool.
Limitations
The first limitation of this study is the relative lack of
experience of the examiners. The researchers tried to
Effect of exams on prevalence of trigger points and head posture
minimize the possible bias by specific training, strict pro-
tocol and double (by both examiners, blinded to results of
each other) evaluation of MTrPs. Only consensus results
were recorded.
Another limitation is that the examiners were not blin-
ded as to whether the student was in the exam period or
the semester, which may cause a bias.
The results of the current study pertain to 22e30 years
old university students. It is possible that individuals of
different age or education backgrounds would react
differently in a similar situation.
Conclusions
The results of this study showed a greater number of MTrPs
in cervical and shoulder girdle musculature and a higher
neck pain NRS score during the exam period. However, no
difference in FHP between two periods was established. It
is still unclear whether the stressful nature of academic
examinations, a relevant threat for students, is the main
cause for these findings, or the prolonged mental demand
of preparing for the exams. This question should be further
investigated. The authors suggest that a preventative pro-
gram should be considered for students during their exams,
in order to minimize musculoskeletal disorders and dis-
abilities in the future.
Conflict of interest statement
There were no funding or financial benefits to the authors.
This paper has not been presented in the past in any form.
No conflicts of interest have been reported by the authors
or by any individuals in control of the content of this
article.
Financial support
None.
Acknowledgments
We would like to thank all subjects for participating in this
study.
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