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ABSTRACT: Objective. To evaluate the effects of an 8-week water physical therapy program on cervical and shoulder pain, pressure sensitivity, and the presence of trigger points (TrPs) in breast cancer survivors. Design. Randomized, controlled trial. Setting. To date, no study has investigated effects of water therapy in breast cancer. Patients. Sixty-six breast cancer survivors were randomly assigned into two groups: WATER group, who received a water exercise program or CONTROL group who received the usual care treatment for breast cancer. Interventions. The WATER therapy program consisted of 24 sessions (3 times/week over 8 weeks) of low-intensity exercises in a warm pool (32°C). Each session included 10-minute warm-up period; 35 minutes of aerobic, low-intensity endurance, and core stability training; and a 15-minute cool-down period (stretching and relaxation). Outcomes. Neck and shoulder pain (visual analog scale, 0-100 mm), pressure pain thresholds (PPTs) over C5-C6 zygapophyseal joints, deltoid muscles, second metacarpal, and tibialis anterior muscles, and the presence of TrPs in cervical-shoulder muscles were assessed at baseline and after the 8-week program by an assessor blinded to treatment allocation. Results. The WATER group demonstrated a between-group improvement for neck pain of -31 mm (95% confidence interval [CI]-49 to -22, P < 0.001; effect size 1.1, 0.81-1.75) and for shoulder-axillary of -19 mm (-40 to -04, P = 0.046; effect size 0.70, 0.14-1.40). Improvements were also noted for PPT levels over C5-C6 joints (between-group differences, affected side: 27.7 kPa, 95% CI 3.9-50.4; unaffected: 18.1 kPa, 95% CI 6.1-52.2). No between-group differences for PPT over the remaining points were observed (P > 0.05). Finally, patients in the WATER program showed a greater reduction of active TrPs as compared with the CONTROL group (P < 0.05). Conclusions. An 8-week water therapy program was effective for improving neck and shoulder/axillary pain, and reducing the presence of TrPs in breast cancer survivors as compared with usual care; however, no significant changes in widespread pressure pain hyperalgesia were found.
Pain Medicine 09/2012; · 2.35 Impact Factor
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ABSTRACT: Our aim was to compare the differences in the prevalence and the anatomical localization of referred pain areas of active trigger points (TrPs) between women with myofascial temporomandibular disorder (TMD) or fibromyalgia (FMS). Twenty women (age 46 ± 8 years) with TMD and 20 (age 48 ± 6 years) with FMS were recruited from specialized clinic. Bilateral temporalis, masseter, sternocleidomastoid, upper trapezius, and suboccipital muscles were examined for TrPs. TrPs were identified by palpation and considered active when the pain reproduced familiar pain symptom experienced by the patient. The referred pain areas were drawn on anatomical maps, digitalized and also measured. A new analysis technique based on a center of gravity (COG) method was used to quantitative estimate of the localization of the TrP referred pain areas. Women with FMS exhibited larger areas of usual pain symptoms than women with myofascial TMD (P < 0.001). The COG coordinates of the usual pain on the frontal and posterior pain maps were located more superior in TMD than in FMS. The number of active TrPs was significantly higher in TMD (mean ± SD 6 ± 1) than in FMS (4 ± 1) (P = 0.002). Women with TMD exhibited more active TrPs in the temporalis and masseter muscles than FMS (P < 0.01). Women with FMS had larger referred pain areas than those with TMD for sternocleidomastoid and suboccipital muscles (P < 0.001). Significant differences within COG coordinates of TrP referred pain areas were found in TMD, the referred pain was more pronounced in the orofacial region, whereas the referred pain in FMS was more pronounced in the cervical spine. This study showed that the referred pain elicited from active TrPs shared similar patterns as usual pain symptoms in women with TMD or FMS, but that distinct differences in TrP prevalence and location of the referred pain areas could be observed. Differences in location of referred pain areas may help clinicians to determine the most relevant TrPs for each pain syndrome in spite of overlaps in pain areas.
The Journal of Headache and Pain 08/2012; · 2.43 Impact Factor
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ABSTRACT: High-density topographical sensitivity maps have been developed to visualize nonuniformity deep tissue pain sensitivity in, for example, lateral epicondylitis (LE). The aim of this cadaveric study was to determine the anatomical association between the topographical sensitivity maps over the elbow area and wrist extensor musculature.
A topographical pressure sensitivity map consisting of 12 points forming a 3 × 4 matrix: 4 points in the superior part, 4 points in the middle, and 4 points in the lower part around the lateral epicondyle was marker on a 50-year embalmed cadaver. Color marker pins were inserted into each point. Pins were removed during the process of dissection, but the small holes created by their removal assured accurate relocation.
Progressive dissection revealed that points 1 to 4 (superior line) were placed over the musculotendinous junction and belly of the extensor carpi radialis brevis (ECRB) muscle, points 6 to 8 (middle line) were placed over the musculotendinous junction and belly of the extensor digitorum communis muscle, and points 9 to 12 (inferior line) were located over the musculotendinous junction and belly of the extensor carpi ulnaris muscle. It was also observed that the superficial branch of the radial nerve runs between the belly of the ECRB and extensor digitorum communis muscles.
This study confirmed that anatomical location previously assumed supporting the important wrist extensor muscles, particularly the ECRB, in patients with LE as depicted by pressure pain sensitivity maps. This study also suggests a potential role of the superficial branch of the radial nerve in LE.
Journal of manipulative and physiological therapeutics 05/2012; 35(5):402-6. · 1.06 Impact Factor
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ABSTRACT: Recent evidence suggests that active trigger points (TrPs) in neck and shoulder muscles contribute to tension-type headache. Active TrPs within the suboccipital, upper trapezius, sternocleidomastoid, temporalis, superior oblique and lateral rectus muscles have been associated with chronic and episodic tension-type headache forms. It seems that the pain profile of this headache may be provoked by referred pain from active TrPs in the posterior cervical, head and shoulder muscles. In fact, the presence of active TrPs has been related to a higher degree of sensitization in tension-type headache. Different therapeutic approaches are proposed for proper TrP management. Preliminary evidence indicates that inactivation of TrPs may be effective for the management of tension-type headache, particularly in a subgroup of patients who may respond positively to this approach. Different treatment approaches targeted to TrP inactivation are discussed in the current paper, focusing on tension-type headache. New studies are needed to further delineate the relationship between muscle TrP inactivation and tension-type headache.
Expert Review of Neurotherapeutics 03/2012; 12(3):315-22.
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ABSTRACT: The curricula of all health professionals have an important foundation of human anatomy. A comparison of the anatomy retention between students from different curricula has not been studied. Our aim was to examine the knowledge competency of third-year physical therapy and medical students in carpal bone anatomy.
The testing was conducted on the third-year medical and physical therapy students at Universidad de Granada. Students were given 5 minutes to answer the carpal bone test, a test which requires the identification of the carpal bones in an illustration of the bony skeleton of carpal region. Differences in the distribution of the responses between groups were analyzed using the χ(2) test.
One hundred thirty-four (n = 134) tests were analyzed (n = 54 [41%] physical therapy students, n = 80 [59%] medical students). Only 39 students correctly identified all of the carpal bones (42.6% physical therapy, 20% medical, P < .001). Physical therapy students correctly identified a greater number (P < .001) of carpal bones (mean ± SD, 5.8 ± 2.2) than medical students (mean ± SD, 3.1 ± 2.9). The capitate was the most frequently identified bone in both physical therapy (96%) and medical (46%) students (P < .001). The hamate bone was the least frequently identified bone by medical students (n = 29, or 36.3%), whereas the trapezoid bone was the least frequently identified bone by physical therapy students (n = 35, or 64.8%).
There are few studies investigating anatomical knowledge levels between disciplines. This study found that physical therapy students exhibited better retention of anatomy of the carpal bones than medical students.
Journal of manipulative and physiological therapeutics 02/2012; 35(2):121-6. · 1.06 Impact Factor
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ABSTRACT: This study aimed to determine differences in sleep quality between patients with mechanical neck pain, patients with whiplash (WAD) pain, and healthy controls and to determine the relationship between the intensity of ongoing pain, disability, and sleep quality.
Nineteen patients with mechanical neck pain (4 men, 15 women; age, 40 ± 16 yrs), 22 with WAD (4 men, 18 women; age, 38 ± 15 yrs), and 18 comparable controls (4 men, 14 women; age, 41 ± 13 yrs) completed the Pittsburgh Sleep Quality Index to assess sleep quality. A numerical pain rate scale (0-10) and the Neck Disability Index (0-50) were collected for assessing neck pain and disability.
Significant differences in sleep quality (P < 0.001), sleep latency (P = 0.005), sleep efficiency (P = 0.002), sleep disturbances (P < 0.001), use of sleeping medication (P < 0.001), daytime dysfunction (P < 0.001), and total Pittsburgh Sleep Quality Index score (P < 0.001) but not for sleep duration (P = 0.096) were found; patients with mechanical neck pain and WAD pain exhibited higher scores in all components compared with healthy controls. Seventeen (77%) patients with WAD and 13 (68%) with mechanical neck pain reported poor sleep quality (Pittsburgh Sleep Quality Index score, >8). Significant positive correlations between mean intensity of ongoing pain with sleep quality (r(s) = 0.693; P < 0.001); sleep duration (r(s) = 0.433; P = 0.044); sleep efficiency (r(s) = 0.644; P = 0.001) and total Pittsburgh Sleep Quality Index score (r(s) = 0.643; P = 0.001) were found in patients with WAD pain; the higher the intensity of ongoing pain, the worse the sleep quality.
Sleep disturbances are a common finding in individuals with neck pain and are associated with the intensity of ongoing pain in WAD. It seems essential to address the ongoing cycle of pain and sleep disturbances as an integral part of the treatment of patients with neck pain.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 12/2011; 91(7):584-91. · 1.56 Impact Factor
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ABSTRACT: In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.
The Journal of manual & manipulative therapy 11/2011; 19(4):201-11.
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ABSTRACT: To compare differences in the prevalence and the anatomical localization of the referred pain areas of active trigger points (TrPs) in head and neck musculature between adults and children with chronic tension-type headache (CTTH).
A cross-sectional study.
Some studies had found that referred pain from active TrPs reproduce the head pain pattern in adults. No study has compared clinical differences between referred pain patterns elicited by active TrPs between adults and children with CTTH.
Twenty adults (10 men, 10 women, mean age: 41 ± 11 years) and 20 children (10 boys, 10 girls, mean age: 8 ± 2 years) with CTTH were included.
Bilateral temporalis, sternocleidomastoid, upper trapezius, and suboccipital muscles were examined for TrPs. TrPs were identified by palpation and considered active when local and referred pains reproduce the headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured. An analysis technique based on a center of gravity (COG) method was used to provide a quantitative estimate of the localization of the TrP referred pain areas.
Adults with CTTH exhibited a greater years with headache, higher intensity, and longer headache duration (P < 0.05) compared with children. The COG coordinates of the spontaneous pain on the dominant side were located more anterior (higher X-value), and spontaneous pain in the frontal and posterior areas was located more inferior (lower Y-value) in adults than in children. The number of active muscle TrPs was significantly higher (P = 0.001) in adults with CTTH (mean ± standard deviation [SD]: 4 ± 0.8) as compared with children (mean ± SD: 3 ± 0.7). Children with CTTH had larger referred pain areas than adults for upper trapezius, sternocleidomastoid, and temporalis (P < 0.001) muscles. The COG coordinates of the referred pain areas of temporalis and sternocleidomastoid muscle TrPs were more inferior (lower Y-values) in adults than in children with CTTH.
This study showed that the referred pain elicited from active TrPs shared similar pain patterns as spontaneous CTTH in adults and children. Differences in TrP prevalence and location of the referred pain areas can be observed between adults and children with CTTH.
Pain Medicine 08/2011; 12(10):1453-63. · 2.35 Impact Factor
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ABSTRACT: Our aim was to investigate the relationship between Val158Met polymorphisms, headache, and pressure hypersensitivity in children with chronic tension-type headache (CTTH). A case-control study with blinded assessor was conducted. Seventy children with CTTH associated with pericranial tenderness and 70 healthy children participated. After amplifying Val158Met polymorphism by polymerase chain reactions, we assessed genotype frequencies and allele distributions. We classified children according to their Val158Met polymorphism: Val/Val, Val/Met, Met/Met. Pressure pain thresholds (PPT) were bilaterally assessed over the temporalis, upper trapezius, second metacarpal, and tibialis anterior muscles. The distribution of Val158Met genotypes was not significantly different (p = 0.335), between children with CTTH and healthy children, and between boys and girls (p = 0.872). Children with CTTH with the Met/Met genotype showed a longer headache history compared with those with Met/Val (p = 0.001) or Val/Val (p = 0.002) genotype. Children with CTTH with Met/Met genotype showed lower PPT over upper trapezius and temporalis muscles than children with CTTH with Met/Val or Val/Val genotype (p < 0.01). The Val158Met catechol-O-methyltransferase (COMT) polymorphism does not appear to be involved in predisposition to suffer from CTTH in children; nevertheless, this genetic factor may be involved in the phenotypic expression, as pressure hypersensitivity was greater in those CTTH children with the Met/Met genotype.
Pediatric Research 06/2011; 70(4):395-9. · 2.70 Impact Factor
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ABSTRACT: : The aim of this study was to analyze the differences in deficits in fine motor control and pinch grip force between patients with minimal, moderate/mild, or severe carpal tunnel syndrome (CTS) and healthy age- and hand dominance-matched controls.
: A case-control study was conducted. The subtests of the Purdue Pegboard Test (one-hand and bilateral pin placements and assemblies) and pinch grip force between the thumb and the remaining four fingers of the hand were bilaterally evaluated in 66 women with minimal (n = 16), moderate (n = 16), or severe (n = 34) CTS and in 20 age- and hand-matched healthy women. The differences among the groups were analyzed using different mixed models of analysis of variance.
: A two-way mixed analysis of variance revealed significant differences between groups, not depending on the presence of unilateral or bilateral symptoms (side), for the one-hand pin placement subtest: patients showed bilateral lower scores compared with controls (P < 0.001), without differences among those with minimal, moderate, or severe CTS (P = 0.946). The patients also exhibited lower scores in bilateral pin placement (P < 0.001) and assembly (P < 0.001) subtests, without differences among them. The three-way analysis of variance revealed significant differences among groups (P < 0.001) and fingers (P < 0.001), not depending on the presence of unilateral/bilateral symptoms (P = 0.684), for pinch grip force: patients showed bilateral lower pinch grip force in all fingers compared with healthy controls, without differences among those with minimal, moderate, or severe CTS.
: The current study revealed similar bilateral deficits in fine motor control and pinch grip force in patients with minimal, moderate, or severe CTS, supporting that fine motor control deficits are a common feature of CTS not associated with electrodiagnostic findings.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 06/2011; 90(6):443-51. · 1.56 Impact Factor
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ABSTRACT: To determine the differences in widespread pressure pain and thermal hypersensitivity in women with minimal, moderate, and severe carpal tunnel syndrome (CTS) and healthy controls.
A total of 72 women with CTS (19 with minimal, 18 with moderate, and 35 with severe) and 19 healthy age-matched women participated. Pressure pain thresholds were bilaterally assessed over the median, ulnar, and radial nerves, the C5 to C6 zygapophyseal joint, the carpal tunnel, and the tibialis anterior muscle. In addition, warm and cold detection thresholds and heat and cold pain thresholds were bilaterally assessed over the carpal tunnel and the thenar eminence. All outcome parameters were assessed by an assessor blinded to the participant's condition.
No significant differences in pain parameters among patients with minimal, moderate, and severe CTS were found. The results showed that PPT were significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the carpal tunnel, C5 to C6 zygapophyseal joint, and the tibialis anterior muscle in patients with minimal, moderate, or severe CTS as compared with healthy controls (all, P<0.001). In addition, patients with CTS also showed lower heat pain threshold and reduced cold pain threshold compared with controls (P<0.001). No significant sensory differences between minimal, moderate, or severe CTS were found.
The similar widespread pressure and thermal hypersensitivity in patients with minimal, moderate, or severe CTS and pain intensity suggests that increased pain sensitivity is not related to electrodiagnostic findings.
The Clinical journal of pain 05/2011; 27(9):747-54. · 3.01 Impact Factor
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ABSTRACT: The aim of this study was to investigate whether generalized deep tissue hyperalgesia exists in patients with chronic unilateral lateral epicondylalgia (LE).
A total of 26 LE patients (10 males and 16 females, aged 25 to 63 y) and 20 healthy comparable matched controls (aged 26 to 61 y) were recruited and pressure pain threshold (PPT) was assessed bilaterally over the median, ulnar, and radial nerve trunks, the lateral epicondyle, C5-C6 zygapophyseal joint, and the tibialis anterior muscle in a blind design.
PPT was significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the lateral epicondyle, the C5-C6 zygapophyseal joint, and tibialis anterior muscle in patients with LE than healthy controls (all P<0.001). PPTs over those measured points was negatively related to current elbow pain intensity (all P<0.05). A more significant decrease in PPTs were present in females (all P<0.05).
This revealed a widespread mechanical hypersensitivity in patients with LE, which suggest that central sensitization mechanisms are involved in patients with unilateral LE. The generalized decrease in PPT levels was associated with elbow pain intensity, supporting a role of peripheral sensitization mechanisms in the initiation or maintenance of central sensitization mechanisms. In addition, females may be more prone to the development of generalized mechanical hypersensitivity.
The Clinical journal of pain 09/2009; 25(7):555-61. · 3.01 Impact Factor
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ABSTRACT: The aim of this study was to investigate whether bilateral widespread pressure hypersensitivity exists in patients with unilateral carpal tunnel syndrome. A total of 20 females with carpal tunnel syndrome (aged 22-60 years), and 20 healthy matched females (aged 21-60 years old) were recruited. Pressure pain thresholds were assessed bilaterally over median, ulnar, and radial nerve trunks, the C5-C6 zygapophyseal joint, the carpal tunnel and the tibialis anterior muscle in a blinded design. The results showed that pressure pain threshold levels were significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the carpal tunnel, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with unilateral carpal tunnel syndrome as compared to healthy controls (all, P < 0.001). Pressure pain threshold was negatively correlated to both hand pain intensity and duration of symptoms (all, P < 0.001). Our findings revealed bilateral widespread pressure hypersensitivity in subjects with carpal tunnel syndrome, which suggest that widespread central sensitization is involved in patients with unilateral carpal tunnel syndrome. The generalized decrease in pressure pain thresholds associated with pain intensity and duration of symptoms supports a role of the peripheral drive to initiate and maintain central sensitization. Nevertheless, both central and peripheral sensitization mechanisms are probably involved at the same time in carpal tunnel syndrome.
Brain 04/2009; 132(Pt 6):1472-9. · 9.46 Impact Factor
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ABSTRACT: Referred pain and pain characteristics evoked from the extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis, and brachioradialis muscles was investigated in 20 patients with lateral epicondylalgia (LE) and 20-matched controls.
Both groups were examined for the presence of myofascial trigger points (TrPs) in a blinded fashion. The quality and location of the evoked referred pain, and the pressure pain threshold (PPT) at the lateral epicondyle on the right upper extremity (symptomatic side in patients, and dominant-side on controls) were recorded. Several lateral elbow pain parameters were also evaluated.
Within the patient group, the elicited referred pain by manual exploration of 13 out of 20 (65%) extensor carpi radialis brevis muscles, 12/20 (70%) extensor carpi radialis longus muscles, 10/20 (50%) brachioradialis muscles, and 5/20 (25%) extensor digitorum communis muscles, shares similar pain patterns as their habitual lateral elbow and forearm pain. The mean number of muscles with TrPs for each patient was 2.9 [95% confidence interval (CI) 1,4] of which 2 (95% CI 1,3) were active, and 0.9 (95% CI 0,2) were latent TrPs. Control participants only had latent TrPs (mean: 0.4; 95% CI 0,2). TrP occurrence between the 2 groups was significantly different for active TrPs (P<0.001), but not for latent TrPs (P>0.05). The referred pain pattern was larger in patients than in controls, with pain referral to the lateral epicondyle (proximally) and to the dorso-lateral aspect of the forearm in the patients, and confined to the dorso-lateral aspect of the forearm in the controls. Patients with LE showed a significant (P<0.001) lower PPT (mean: 2.1 kg/cm; 95% CI 0.8, 4 kg/cm) as compared with controls (mean: 4.5 kg/cm; 95% CI 3, 7 kg/cm). Within the patient group, PPT at the lateral epicondyle was negatively correlated with both the total number of TrPs (rs=-0.63; P=0.003) and the number of active TrPs (rs=-0.5; P=0.02): the greater the number of active TrPs, the lower the PPT at the lateral epicondyle.
Our results suggest that in patients with LE, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual elbow and forearm pain, consistent with active TrPs. Lower PPT and larger referred pain patterns suggest that peripheral and central sensitization exists in LE.
Clinical Journal of Pain 05/2007; 23(4):353-60. · 2.81 Impact Factor
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ABSTRACT: The aim of the present study was to investigate the presence of active and latent muscle trigger points (TrPs) in the forearm musculature on both affected and unaffected sides in patients with lateral epicondylalgia (LE) and healthy controls.
Twenty-five patients with LE and 20 healthy matched controls participated. Both groups were examined for the presence of TrPs in the extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis, and brachioradialis muscles in a blinded fashion. TrPs were identified in both affected and unaffected sides within the patient group. In the control group, TrPs were explored around the dominant side. Pressure pain thresholds (PPTs) were assessed on both affected and unaffected arms.
In the patient group, the number of active muscle TrPs in the affected side was 3.1 [95% confidence interval (CI): 2.8-3.4], whereas in the unaffected arm, only latent TrPs were found (mean: 2.2; 95% CI: 1.8-2.6). Active TrPs were only located on the affected side (P<0.001). Within the control group, the number of latent TrPs in the dominant arm was 0.4 (95% CI: 0.0-0.7), which was significantly lower than the number of latent TrPs in the unaffected arm (P<0.001) in patients. Therefore, latent muscle TrPs in the forearm musculature were associated with the unaffected side in the patient group as compared with the dominant arm in healthy controls: extensor carpi radialis brevis [odds ratio (OR)=66 (95% CI: 9.9-48.8)], extensor carpi radialis longus [OR=16 (95% CI: 3.7-29.6)], brachioradialis [OR=2.6 (95% CI: 0.3-27.1)], and extensor digitorum communis [OR=0.5 (95% CI: 0.4-0.8)]. PPTs were lower around the affected side than around the unaffected arm in patients (mean+/-SD: 274.5+/-90.4 KPa vs. 465.4+/-140.7 KPa; P<0.001) in the patient group. Finally, PPT from the extensor digitorum muscle in those patients with active TrPs (mean+/-SD: 244+/-70.4 KPa) was significantly lower (P<0.001) than PPT levels of patients with no TrP in the same muscle (mean+/-SD: 370+/-83.4 KPa).
Latent TrPs are present in forearm muscles on the unaffected side in patients with LE where active TrPs contribute to the pain on the affected arm. The presence of latent TrPs on the unaffected side in unilateral LE may be related to central sensitization and be a mechanism explaining bilateral pain in some patients with unilateral pathologies.
The Clinical journal of pain 24(9):802-7. · 3.01 Impact Factor
