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Signs and Symptoms of the Myofascial Pain Syndrome: A National Survey of Pain Management Providers
Abstract
The goal of this study was to assess clinical consensus regarding whether myofascial pain syndrome (MPS) is a legitimate and distinct diagnosis as well as the signs and symptoms characterizing MPS.
A standardized mailed survey with return postage provided.
A total of 1,663 American Pain Society members in medically related disciplines listed in the 1996/1997 directory.
A standardized survey assessing clinical opinion regarding whether MPS is a legitimate diagnosis, whether MPS is a clinical entity distinct from fibromyalgia, and the signs and symptoms believed to be "essential to," "associated with," or "irrelevant to" to the diagnosis of MPS.
Of the 403 surveys returned, 88.5% respondents reported that MPS was a legitimate diagnosis, with 81% describing MPS as distinct from fibromyalgia. The only signs and symptoms described as essential to the diagnosis of MPS by greater than 50% of the sample were regional location, presence of trigger points, and a normal neurologic examination. Regarding the signs and symptoms considered to be essential or associated with MPS, more than 80% of respondents agreed on regional location, trigger points, normal neurologic examination, reduced pain with local anesthetic or "spray and stretch," taut bands, tender points, palpable nodules, muscle ropiness, decreased range of motion, pain exacerbated by stress, and regional pain described as "dull," "achy," or "deep." Sensory or reflex abnormalities, scar tissue, and most test results were considered to be irrelevant to the diagnosis of MPS by a large proportion of the respondents.
There was general agreement across specialties that MPS is a legitimate diagnosis distinct from fibromyalgia. There was a high level of agreement regarding the signs and symptoms essential or associated with a diagnosis of MPS. Differences across specialties are discussed. This survey provides a first step toward the development of consensus-based diagnostic criteria for MPS, which can then be validated empirically.
... Many hypotheses of how trigger points evolve are based on the opinions of experienced clinicians who treat and research trigger points. Trigger points are most often discussed as a component of myofascial pain syndromes where widespread or regional muscular pain is associated with hyperalgesia, psychological disturbance, and significant restriction of daily function [44]. Trigger points are 2-5 mm diameter points of increased hypersensitivity in palpable bands of the skeletal muscle, tendons, and ligaments with decreasing hypersensitivity as one palpates the band further away from the trigger point. ...
... Each splint is described in detail by its advocate. The following factors should be taken into account during splint construction [44,49]: ...
Myofascial pain dysfunction syndrome (MPDS) is a stomatognathic system disturbance,
which consists of pain, jaw movement irregularities, and muscle spasm. Hyperexcitation
of peripheral sensory neurons causes a reaction of induction in the motor neuron and
then spasms of the masticatory muscles follow. Long-term spasm causes muscular pain
and irregular mandibular motion. Pain is the most important inducer and therefore
must be managed firstly in order to manage the muscle spasms. Symptomatic treatment
approaches may be useful, but after symptom elimination, etiologically based treatment
must be provided to the patient. The neurophysiology of the stomatognathic system
must be well understood to determine a proper treatment for the MPDS condition. Both
symptomatic and etiological treatment methods have been proposed by differing authors
as potential solutions for MPDS. Occlusal splints are a commonly used treatment for
relieving MPDS symptoms. Alternatively, some forms of occlusal adjustment (not all)
have been shown to be an effective, permanent treatment course for myofascial pain dysfunction
syndrome. This chapter describes the neural controls over the stomatognathic
system and how that system can neurologically promote the MPDS disease state. It then
details the computer-guided MPDS occlusal adjustment treatment known as disclusion
time reduction that has been shown in many published studies to be a highly effective
myofascial pain dysfunction syndrome (MPDS) therapy.
... Myofascial pain is prevalent with 30 % of individuals seeking care for pain at a primary care office meeting the criteria for myofascial pain. While the definition of a trigger point can vary, there is general agreement among clinicians and scientists that myofascial pain is a separate diagnosis from fibromyalgia [105] and that trigger points contribute to myofascial pain syndrome [106]. ...
Skeletal muscle is the largest organ system in the human body and plays critical roles in athletic performance, mobility, and disease pathogenesis. Despite growing recognition of its importance by major health organizations, significant knowledge gaps remain regarding skeletal muscle health and its crosstalk with nearly every physiological system. Relevant public health challenges like pain, injury, obesity, and sarcopenia underscore the need to accurately assess skeletal muscle health and function. Feasible, non-invasive techniques that reliably evaluate metrics including muscle pain, dynamic structure, contractility, circulatory function, body composition, and emerging biomarkers are imperative to unraveling the complexities of skeletal muscle. Our concise review highlights innovative or overlooked approaches for comprehensively assessing skeletal muscle in vivo. We summarize recent advances in leveraging dynamic ultrasound imaging, muscle echogenicity, tensiomyography, blood flow restriction protocols, molecular techniques, body composition, and pain assessments to gain novel insight into muscle physiology from cellular to whole-body perspectives. Continued development of precise, non-invasive tools to investigate skeletal muscle are critical in informing impactful discoveries in exercise and rehabilitation science.
... Although the precise mechanism underlying MTrPs has not yet been elucidated, according to hypotheses formulated in recent studies, involuntary muscle shortening due to muscle tissue injury or overuse [4,5] and the accumulation of microtrauma due to repetitive overuse, muscle imbalance, and dysfunction of postural alignment contribute to the development of MTrPs [6]. MTrPs present with a characteristic referred type of pain and can restrict functional movement by limiting the range of motion of the affected tissue [7,8]. In addition, MTrPs appear frequently in patients with mechanical neck pain and are associated with muscle shortening and a lowered pressure pain threshold (PPT) [9,10]. ...
Background
Active release technique (ART) and strain-counterstrain (SCS) have been reported to be beneficial for patients with trigger point pain. Therefore, this study of 45 patients with chronic neck pain aimed to compare the effects of 4 weeks of physical therapy with the ART and SCS manipulation with massage alone, evaluated before and after treatment, using the visual analog scale (VAS) for pain, the neck disability index (NDI), and the pressure pain threshold (PPT).
Material/Methods
The participants were 45 adults with neck pain lasting >12 weeks, divided into the ART group (n=15), SCS group (n=15), and control group (n=15). All groups received clinical massage (CM) for 15 min twice a week for 4 weeks. The control group received only CM, the ART group received CM and ART for 15 min twice a week for 4 weeks, and the SCS group received CM and SCS for 15 min twice a week for 4 weeks. VAS, NDI, and PPT were measured before and after the interventions.
Results
In all groups, there were significant changes in VAS, NDI, and PPT after the interventions (P<0.05), and there was a significant difference among groups in the difference before and after intervention (P<0.05). VAS and NDI showed the greatest difference among before and after intervention in the ART group (VAS pre-post 3.38±0.76, NDI pre-post 5.69±2.78). PPT showed the greatest difference among before and after intervention in the SCS group (PPT pre-post 1.75±0.62).
Conclusions
The ART technique and the SCS technique effectively reduced neck pain and neck disorders in adults with chronic neck pain.
... These findings validate and complement research that demonstrated that all patients experience pain and hyperalgesia following the DN of a latent MTrP, which typically lasts less than 72 h [41]. It was demonstrated that IC is a highly effective method for treating MTrPs, resulting in instant pain alleviation [42]. ...
Background:
Chronic neck pain (CNP) may be associated with latent myofascial trigger points (MTrPs) in the levator scapulae (LS), which can be treated with ischemic compression (IC) and dry needling (DN). Variables and elastography changes are evaluated to compare the short-term efficacy of two treatments with DN.
Methods:
A randomized clinical trial is conducted with 80 participants in two groups: the DN group (n = 40) and IC group (n = 40). The duration is 12 weeks, and mechanical heterogeneity index, pressure pain threshold (PPT), and pain intensity are measured at baseline, immediately after, 48 h after, and one week after treatment.
Results:
Statistically significant changes were immediately observed between the two groups: PPT decreased in the DN group (p = 0.05), while it increased in the IC group. At 48 h and one week after treatment, these values increased in the DN group and remained higher than in the IC group. The heterogeneity index improved in both groups but more significantly in the DN group than in the IC group.
Conclusions:
In subjects with CNP who had latent plus hyperalgesic MTrPs in the LS muscle, DN outperformed IC in PPT, pain intensity, and mechanical heterogeneity index at 48 h and one week after initiating therapy.
... Trigger points have several causes. Some common causes of trigger points are: birth trauma, an injury sustained in a fall or accident, poor posture, or overexertion [11,12,13,14,15] . Most heel pain is produced by trigger points in the calf muscle. ...
... Appropriate identification and management of MPS has been identified as an important area of emphasis within health care. 3,5,7,9,10 ...
Myofascial pain syndrome is a clinical condition that has been increasingly recognized over the past thirty years. Myofascial pain syndrome is characterized by the presence of hyperirritable nodules, called myofascial trigger points, which cause chronic pain within a single quadrant of the body. This article will provide an overview of the diagnosis of myofascial pain syndrome as well as the most common forms of management for this condition. Additionally, this article proposes the use of a subset of myofascial trigger point diagnostic criteria in an attempt standardize the identification of myofascial pain syndrome across various health care practitioners. It is recommended that clinicians incorporate the patient's preferences, the clinician's previous experiences, and the best available evidence in an attempt to provide evidence-based care for patients with myofascial pain syndrome.
... Two of the methods that have the most evidence for the treatment of MTrPs are IC and DN [27][28][29][30][31][32][33][34][35][36][37]. Studies show that DN is considered one of the most effective techniques for the direct inactivation of MTrPs, improving symptomatology and relieving pain [6,8]. ...
Background:
The presence of latent myofascial trigger points (MTrPs) in the gluteus medius is one of the possible causes of non-specific low back pain. Dry needling (DN) and ischemic compression (IC) techniques may be useful for the treatment of these MTrPs.
Methods:
For this study, 80 participants were randomly divided into two groups: the dry needling group, who received a single session of DN to the gluteus medius muscle plus hyperalgesia (n = 40), and the IC group, who received a single session of IC to the gluteus medius muscle plus hyperalgesia (n = 40). Pain intensity, the pressure pain threshold (PPT), range of motion (ROM), and quality of life were assessed at baseline, immediately after treatment, after 48 h, and one week after treatment.
Results:
Statistically significant differences were shown between the two groups immediately after the intervention, showing a decrease in PPT (p < 0.05) in the DN group and an increase in PPT in the IC group. These values increased more and were better maintained at 48 h and after one week of treatment in the DN group than in the IC group. Quality of life improved in both groups, with greater improvement in the DN group than in the IC group.
Conclusions:
IC could be more advisable than DN with respect to UDP and pain intensity in the most hyperalgesic latent MTrPs of the gluteus medius muscle in subjects with non-specific low back pain, immediately after treatment. DN may be more effective than IC in terms of PPT, pain intensity, and quality of life in treating latent plus hyperalgesic gluteus medius muscle MTrPs in subjects with non-specific low back pain after 48 h and after one week of treatment.
... e most frequent cause of muscular pain is the myofascial pain syndrome (MPS) [1]. MPS is a collection of known sensory, motor, and autonomic symptoms caused by myofascial trigger points (MTrPs) [2,3]. Myofascial trigger points are hyperirritable nodules within taut bands of skeletal muscle responsible for sensory, motor (sti ness, weakness, and restricted range of motion), and autonomic dysfunction [3]. ...
Numerous studies have suggested that the myofascial trigger points are responsible for most of the myofascial pain syndrome, so it seems reasonable that its destruction is a good therapeutic solution. The effectiveness of dry needling (DN) has been confirmed in muscles with myofascial trigger points, hypertonicity, and spasticity. The objective of this study is to analyze the need of repetitive punctures on muscles in different situations. The levator auris longus (LAL) muscle and gastrocnemius muscle from adult male Swiss mice were dissected and maintained alive, while being submerged in an oxygenated Ringer’s solution. DN was evaluated under four animal models, mimicking the human condition: normal healthy muscles, muscle fibers with contraction knots, muscles submerged in a depolarizing Ringer solution (KCl-CaCl2), and muscles submerged in Ringer solution with formalin. Thereafter, samples were evaluated with optical microscopy (LAL) and scanning electron microscopy (gastrocnemius). Healthy muscles allowed the penetration of needles between fibers with minimal injuries. In muscles with contraction knots, the needle separated many muscle fibers, and several others were injured, while blood vessels and intramuscular nerves were mostly not injured. Muscles submerged in a depolarizing solution inducing sustained contraction showed more injured muscular fibers and several muscle fibers separated by the needle. Finally, the muscles submerged in Ringer solution with formalin showed a few number of injured muscular fibers and abundant muscle fibers separated by the needle. Scanning electron microscopy images confirm the optical analyses. In summary, dry needling is a technique that causes mild injury irrespective of the muscle tone.
... Myofascial pain syndrome (MPS) is a regional pain syndrome that causes local or referred pain due to hyperirritable trigger points that are localized within taut bands in the musculoskeletal system. [1][2][3] MPS is the most common cause of chronic pain [4,5] and occurs at a rate of approximately 30% in primary care clinics [6] and 85-93% in pain clinics. [5,7] The syndrome primarily affects adults and is mainly seen in women. ...
Objectives:
Myofascial pain syndrome (MPS) is a regional pain syndrome that causes pain due to hyperirritable trigger points in the musculoskeletal system. Trapezius is one of the most commonly affected muscles in MPS. We aimed to evaluate the efficacy of an ultrasound-guided interfascial block of the trapezius muscle in patients with MPS.
Methods:
The records of patients who underwent an ultrasound-guided interfascial block of the trapezius between November 2019 and October 2020 were retrospectively examined. The pain levels of the patients were evaluated with the numeric rating scale (NRS). Patients with a reduction in pain ≥50% after the procedure were considered to have benefited from the procedure.
Results:
A total of 54 patients (41 women and 13 men) were evaluated. The mean NRS values of the patients were 7.16 (5-9) before the procedure, 3.31 (0-8) 10 min after the procedure, and 3.37 (0-8) 1 week after the procedure. The number of patients who benefited from the procedure was 40 (74.07%) 10 min after the procedure. The number of patients who benefited from the procedure for up to 1 week, 1-2 weeks, 2 weeks-1 month, 1-3 months, and more than 3 months after the procedure was 38 (70.37%), 36 (66.66%), 31 (57.40%), 26 (48.14%), and 17 (31.48%), respectively.
Conclusion:
Pain relief lasting for months was achieved in most of the patients. We believe that ultrasound-guided interfascial block of the trapezius is effective for the treatment of MPS.
... Regular follow-up is essential after splint usage. This helps to identify any complications as a result of splint therapy which might mandate stoppage of splint therapy altogether [33,34]. The specific type of splint and duration of treatment must be carefully titrated for individual patients. ...
Myofascial Pain Dysfunction Syndrome or myofascial pain disorder is one among the triad of disturbances that is encompassed within the umbrella term, TMJ disorders. Due to a lack of consensus on definitive symptoms and mode of diagnosis, it continues to remain an elusive entity for clinicians working with head and neck disorders and dentists alike. Additionally, There is a general lack of simplification in literature to enhance understanding and this is further complicated by the use of multiple descriptive terminologies to refer to the disorder. It is the objective of this chapter to provide a comprehensive overview of the subject for the reader, to clarify the various nuances of diagnosis, treatment planning and management modalities in addition to throwing light on the evolving terminologies, causative mechanisms and recent trends in MPDS management. The author has also highlighted the importance of a multi modality management approach, psychological rehabilitation with long term patient follow up. The authors personal experience with the use of specialised splints has been elucidated with relevant clinical case scenarios.
... Latent TrPs cause no pain until irritated by intense heat or cold. On the other hand, active TrPs can produce constant pain, decreased muscle tone, strength and range of motion (ROM), thus leading to disability [4] . TrPs can occur in any muscle, but it is usually seen to occur in muscles that help maintain posture [5] . ...
Objective: This study aimed to determine the effectiveness of the Positional Release Therapy (PRT) for treating Myofascial Trigger Points (MTrPs) in the upper trapezius muscle on outcomes of pain, Range of Motion (ROM) and disability. Methods: Twenty-one patients of mean age 29±12.48 years were screened for inclusion/exclusion criteria. The PRT was administered three times a week for 4 weeks. The verbal Numerical Pain Rating scale (NPRS), active cervical contralateral flexion (ACLF) and Neck Disability Index (NDI) were recorded at baseline, 2 and 4 weeks. Descriptive statistics in the form of mean and standard deviation were used to analyze the data. Results and Conclusion: Increase in ROM and alleviated levels of pain and disability were noted in all participants post treatment. This case series suggests that a short-term manual therapy technique, such as the PRT would be beneficial in treating individuals with upper trapezius TrPs.
... It can be defined as a hyperirritable spot along a taut band of skeletal muscle that triggers pain on compression or stretch giving rise to a typical referred pain pattern [1] . MTrPs have been associated with limited Range of Motion (ROM) and hyperalgesia and should therefore be addressed as part of a comprehensive physical therapy regimen as they may potentially restrict functional performance [2] . MTrPs are not limited to specific muscle groups, however, the most common sites are levator scapula, upper trapezius, sternocleidomastoid, scalene and quadratus lumborum, all of which actively assist in stabilizing posture [3] . ...
Objective: This study aimed to determine the effectiveness of the Integrated Neuromuscular Inhibition Technique (INIT) for treating Myofascial Trigger Points (MTrPs) in the upper trapezius muscle on outcomes of pain, Range of Motion (ROM) and disability. Methods: 18 patients mean age 27± of 14.78 years were screened for inclusion/exclusion criteria. The INIT was administered three times a week for 4 weeks. The verbal Numerical Pain Rating scale (NPRS), cervical lateral flexion ROM and Neck Disability Index (NDI) were recorded at baseline, 2 and 4 weeks. Results and Conclusion: There were positive changes in all outcome measures for all eighteen participants. An increase in ROM and reduced levels of pain and disability were noted. This case series suggests that a short-term multimodal therapy would be beneficial for individuals with upper trapezius MTrPs. Important preliminary data was collected that will inform more rigorous research in this field of research.
... Myofascial pain syndrome (MPS) is a regional pain syndrome arising in muscles and muscle fascia, characterized by tenderness to palpation, limited range of motion and the presence of taut bands [1][2][3]. The diagnosis of MPS rests strictly on clinical criteria, including a history and physical examination of the involved muscles [4][5][6]. ...
Myofascial pain syndrome is widely considered to be among the most prevalent pain conditions, both in the community and in specialized pain clinics. While myofascial pain often arises in otherwise healthy individuals, evidence is mounting that its prevalence may be even higher in individuals with various comorbidities. Comorbid myofascial pain has been observed in a wide variety of medical conditions, including malignant tumors, osteoarthritis, neurological conditions, and mental health conditions. Here, we review the evidence of comorbid myofascial pain and discuss the diagnostic and therapeutic implications of its recognition.
... Researches of various kinds of treatments show strong evidence that manual therapy has a positive effect on patients with long term low back dysfunction, but there is still no evidence for the best type of modality chosen (Harden et al., 2000). ...
Introduction: Chronic Mechanical Low Back Dysfunction (CMLBD) is the most common problem of the working-age population in modern industrial society; it causes a substantial economic burden due to the wide use of medical services and absence from work. Aim of work: To investigate the effect of positional release technique on patients with chronic mechanical low back pain. Materials and Methods: Thirty two patients from both sexes were diagnosed with CMLBP, aged 20 to 45 years and were divided randomly into two equal groups; sixteen patients each; group A (control group) received therapeutic exercises that include (Stretch and Strength exercises for back and abdominal muscles). Group B (experimental group) received therapeutic exercises with positional release technique; treatment was applied 3 days/week for 4 weeks. Pain was measured by Visual Analogue Scale, Lumbar range of motion was measured by Inclinometer and Functional disability was measured by Oswestry disability scale. Measurements were taken at two intervals pre-treatment and post-treatment. Results: Data obtained was analyzed via paired and unpaired t-Test. There were statistical differences between the 2 groups, where the experimental group showed greater improvement than control group. Conclusion: Positional release technique
... The integrated hypothesis is one of the most widely accepted pathophysiological explanations of myofascial pain syndrome (MPS) (10,29). According to this hypothesis, an excessive secretion of ACh initiates a cascade of events leading to the formation of contraction knots. ...
... El síndrome de dolor miofascial (SDM) se define como un conjunto de síntomas sensoriales, motores y autonómicos causados por los puntos gatillo miofasciales (PGM) 1,2 . Un PGM es una zona hiperirritable en un músculo esquelético, asociada con un nódulo palpable y sensible, situada en una banda tensa de músculo. ...
Introduction: The technique of dry needling involves piercing the skin with a solid needle and destroys an area of myofascial trigger points. Different types of needles and manipulations could be a factor to consider for choosing the needle and its application.
Objective: To evaluate possible modifications of the tips of the needles used during the DN.
Material and methods: Three types of needles were analysed: 0.25 mm and 0.32 mm thick (Agu-Punt®) and 0.25 mm (SEIRIN®) with two scanning electron microscopy (FEI Quanta 600 and JEOL JSM 6360LV) to 2,000 magnifications. The needles were evaluated in the following situations: new unused needles; used without gloves; up to 10 insertions in skin; up to 40 insertions in muscle; two to 10 impacts on bone. Occasionally microanalysis was performed by diffusion of RX with an Oxford Instrument, Inca.
Results: New needles showed metallic particles on its surface; when needles were handled without gloves, some dust particles were adhered at their surface; there were no alterations in the morphology of the needles after 10 inserts in the skin or 40 inserts in the muscle; after colliding with the scapula (2 and 10 impacts) only changes were obtained at the tip of a needle depending on the operator. The microanalysis of the needles showed similar metallic composition between different suppliers.
Conclusions: In this study, the tested needles do not show significant defects neither before nor after clinical use by the technique of DN.
... El síndrome de dolor miofascial (SDM) se define como un conjunto de síntomas sensoriales, motores y autonómicos causados por los puntos gatillo miofasciales (PGM) 1,2 . Un PGM es una zona hiperirritable en un músculo esquelético, asociada con un nódulo palpable y sensible, situada en una banda tensa de músculo. ...
Introduction: The technique of dry needling involves piercing the skin with a solid needle and destroys an area of myofascial trigger points. Different types of needles and manipulations could be a factor to consider for choosing the needle and its application.
Objective: To evaluate possible modifications of the tips of the needles used during the DN.
Material and methods: Three types of needles were analysed: 0.25 mm and 0.32 mm thick (Agu-Punt®) and 0.25 mm (SEIRIN®) with two scanning electron microscopy (FEI Quanta 600 and JEOL JSM 6360LV) to 2,000 magnifications. The needles were evaluated in the following situations: new unused needles; used without gloves; up to 10 insertions in skin; up to 40 insertions in muscle; two to 10 impacts on bone. Occasionally microanalysis was performed by diffusion of RX with an Oxford Instrument, Inca.
Results: New needles showed metallic particles on its surface; when needles were handled without gloves, some dust particles were adhered at their surface; there were no alterations in the morphology of the needles after 10 inserts in the skin or 40 inserts in the muscle; after colliding with the scapula (2 and 10 impacts) only changes were obtained at the tip of a needle depending on the operator. The microanalysis of the needles showed similar metallic composition between different suppliers.
Conclusions: In this study, the tested needles do not show significant defects neither before nor after clinical use by the technique of DN.
© 2016 MVClinic. Published by Elsevier España, S.L.U.
... Myofascial trigger points (MTrPs) are defined as hyperirritable spots in a palpable taut band (TB) of skeletal muscle fibers [1]. Accordingly, puncturing or pressing MTrPs can produce local twitch responses accompanied by spontaneous pain and referred pain [2]. Needle electromyography (EMG) [3], surface EMG [4], and ultrasound imaging [5] are valuable tools used to confirm the existence of MTrPs in human subjects. ...
... In the last decade, MTrPs have received greater attention and almost 200 clinical studies have been completed [44]. A survey by American pain specialists has revealed a general agreement that MPS is a legitimate medical diagnosis [45], and since 2005, the International Association for the Study of Pain has included MPS in the Core Curriculum for the Professional Education in Pain [46]. Interestingly, investigations have shown a wide-ranging prevalence of MTrP associated with various painful conditions including endometriosis, interstitial cystitis, and breast cancer [47 & , 48,49], suggesting that MTrP is a common 'pain generator' that could be an epiphenomenon or relevant comorbidity in a wide range of painful conditions. ...
Purpose of review:
Myofascial pain syndrome is a chronic pain condition characterized by the presence of myofascial trigger point, a hyperirritable painful spot involving a limited number of muscle fibers. The literature suggest that myofascial trigger points should be considered peripheral pain generators and this critical review will summarize recent findings concerning the clinical evaluation and the treatment of myofascial trigger points.
Recent findings:
The clinical features of myofascial trigger points and their contribution to the patient pain and disability have been detailed in several recent studies, which support the clinical relevance of the condition. Recent studies reported that manual palpation to identify MTrPs has good reliability, although some limitations are intrinsic to the diagnostic criteria. During the last decade, a plethora of treatments have been proposed and positive effects on pain and function demonstrated.
Summary:
The myofascial trigger point phenomenon has good face validity validity and is clinically relevant. Clinicians are encouraged to consider the contribution of myofascial trigger points to the patient's pain and disability through a careful medical history and a specific manual examination. Patients with myofascial trigger points will benefit from a multimodal treatment plan including dry needling and manual therapy techniques. Internal and external validity of research within the field must be improved.
... A typical case of MPS requires a comprehensive plan: a pertinent history, physical examination (palpation), and systemic evaluation, a battery of laboratory investigation, advanced neuroimaging techniques, ultrasound, and histopathological studies [1][2][3]16,[23][24][25][26][27][28]. However, in our case series the diagnosis of MPS was based on myofascial pain and tenderness of muscle, recognition of taut muscle, palpation of MTrPs, local twitch response, referred pain symptoms such as goose-bumps and numbness, referred pain to other specific regions such as shoulder, neck and back, chest, hands and limitation of motion, and repeated injuries including forceful trauma and muscle strains as described by Gerwin and other researchers [1][2][3][4][7][8][9]11,18,29,30]. Evidently, like in our case series most patients with MPS tend to present with local muscle pain, tenderness, and specific patternreferred pain along a nerve distribution. ...
Background: Myofascial pain syndrome is a common pain condition characterized by a key symptoms and signs, determined by multiple etiologies, comorbid with a variety of systemic diseases and regional pain syndromes and managed by diverse therapies with variable outcomes. Objective: This study aimed to concisely report 11 cases of myofascial pain syndrome managed by myofascial trigger point therapy. Methods: The relevant information about 11 cases was collected prospectively using a semistructured proforma. All patients were diagnosed mainly by detailed history and gold standard palpation method that helps identify taut muscles, tender myofascial trigger points, local twitch response and autonomic manifestations. Results: Most of the patients with variable age and profession presented in emergency room with acute pain, limited motion, weakness, referred pain of specific pattern and associated autonomic signs and symptoms. Myofascial trigger point therapy alone with a timeline of about 30-60 minutes of 1-3sessions brought about good results in all 11 patients (100%) who remained stable at two to three months followup. Conclusion: Myofascial pain syndrome linked with latent or active myofascial trigger points developed due to repeated strains and injuries needs to be diagnosed by history and palpation method, systemic evaluation and laboratory investigations. Though several interventions are used in myofascial pain syndrome, myofascial trigger point massage therapy alone is found to be reasonably effective with excellent results. This clinical case series is calling for double-blind randomized controlled trials among patients with myofascial pain syndrome not only in Saudi Arabia but also in other Middle East countries in future.
... Researches of various kinds of treatments show strong evidence that manual therapy has a positive effect on patients with long term low back dysfunction, but there is still no evidence for the best type of modality chosen (Harden et al., 2000). ...
Introduction: Chronic Mechanical Low Back Dysfunction (CMLBD) is the most common problem of the working-age population in modern industrial society; it causes a substantial economic burden due to the wide use of medical services and absence from work. Aim of work: To investigate the effect of positional release technique on patients with chronic mechanical low back pain. Materials and Methods: Thirty two patients from both sexes were diagnosed with CMLBP, aged 20 to 45 years and were divided randomly into two equal groups; sixteen patients each; group A (control group) received therapeutic exercises that include (Stretch and Strength exercises for back and abdominal muscles). Group B (experimental group) received therapeutic exercises with positional release technique; treatment was applied 3 days/week for 4 weeks. Pain was measured by Visual Analogue Scale, Lumbar range of motion was measured by Inclinometer and Functional disability was measured by Oswestry disability scale. Measurements were taken at two intervals pre-treatment and post-treatment. Results: Data obtained was analyzed via paired and unpaired t-Test. There were statistical differences between the 2 groups, where the experimental group showed greater improvement than control group. Conclusion: Positional release technique
... Researches of various kinds of treatments show strong evidence that manual therapy has a positive effect on patients with long term low back dysfunction, but there is still no evidence for the best type of modality chosen (Harden et al., 2000). ...
Introduction: Chronic Mechanical Low Back Dysfunction (CMLBD) is the most
common problem of the working-age population in modern industrial society; it causes
a substantial economic burden due to the wide use of medical services and absence
from work. Aim of work: To investigate the effect of positional release technique
on patients with chronic mechanical low back pain. Materials and Methods: Thirty
two patients from both sexes were diagnosed with CMLBP, aged 20 to 45 years and
were divided randomly into two equal groups; sixteen patients each; group A (control
group) received therapeutic exercises that include ( Stretch and Strength exercises
for back and abdominal muscles). Group B (experimental group) received therapeutic
exercises with positional release technique; treatment was applied 3 days/week for
4 weeks. Pain was measured by Visual Analogue Scale, Lumbar range of motion
was measured by Inclinometer and Functional disability was measured by Oswestry
disability scale. Measurements were taken at two intervals pre-treatment and posttreatment.
Results: Data obtained was analyzed via paired and unpaired t-Test. There
were statistical differences between the 2 groups, where the experimental group showed
greater improvement than control group. Conclusion: Positional release technique is considered as an effective treatment for reducing pain, functional disability and
increasing lumbar range of motion in individuals with chronic mechanical low back
pain.
Keywords: Chronic Mechanical Low back Pain, Traditional physical therapy program,
Positional release technique, Functional disability.
... On physical examination, clinical signs of tender MTrPs within the taut muscle, local zone tenderness along with referred pain to the specific areas, and local twitch response give further clues to the diagnosis of MPS [1][2][3]7,31]. The MTrP is always located on a taut band of muscle. An active MTrP that causes pain is mostly tender to palpation. ...
Background: Myofascial pain syndrome is a common multifactorial condition that presents with key manifestations and comorbid with many systemic diseases and regional pain syndromes. Objective: This study aims to concisely review clinical, diagnostic and integrative therapeutic aspects of myofascial pain syndrome. Methods: E-searches (2000-2019) using keywords and Boolean operators were made and using exclusion and inclusion criteria, 50 full articles that focused on myofascial pain syndrome were retained for this review. Results: Myofascial pain syndrome is a multidimensional musculoskeletal disorder with ill-understood etiopathogenesis and pathophysiology and characterized by tender taut muscle with myofascial trigger points, muscle twitch response, specific pattern of referred pain and autonomic symptoms. A variety of pharmacological and nonpharmacological therapies with variable efficacy are used in myofascial pain syndrome, the latter modalities such as education, stretching and exercises, moist hot and cold packs, dry needling and myofascial massage or myofascial trigger point massage are used as first line options. Conclusion: Myofascial pain syndrome and trigger points initiated by repeated strains and injuries co-occur with diverse physical diseases and regional pain syndromes, which need comprehensive diagnostic evaluation using multiple methods. Several interventions are used in patients with myofascial pain syndrome who effectively respond to myofascial massage. This study calls for exploring etiopathogenesis and basic pathophysiological mechanisms underlying myofascial pain syndrome in future.
... Myofascial syndrome is a clinical condition characterized by muscle pain related to Myofascial Trigger Points (MTrPs) [1]. The MTrPs are usually associated with (i) hyperalgesia, (ii) referred pain, (iii) behavioural perturbations, and (iv) functional limitations [2]. A MTrP is defined as a hypersensitive nodule located in skeletal muscles [3]. ...
Objective
To analyse the effect of the manual ischemic compression (IC) on the upper limb motor performance (MP) in patients with LTrPs.
Materials and Methods
A quasiexperimental study was performed in twenty subjects allocated to either patients group with LTrPs (PG, n=10) or healthy group with no symptoms (HG, n=10). Subjective pain and linear MP (movement time and Fitts' Law) were assessed before and after a linear tapping task. Data were analysed with mixed factorial ANOVA for intergroup linear motor performance differences and dependent t-student test for intragroup pain differences.
Results
PG had a linear MP lower than the HG before treatment (p < 0.05). After IC, the PG showed a significant decrease of pain (4.07 ± 1.91 p < 0.001). Furthermore, the movement time (15.70 ± 2.05 p < 0.001) and the Fitts' Law coefficient (0.80 ± 0.53 p < 0.001) were significantly reduced. However, one IC session did not allow the PG to get the same MP than the HG (p < 0.05).
Conclusion
The results suggest the IC effectiveness on pain and MP impairment in subjects with LTrPs. However, the MP of these patients is only partially improved after the IC application.
... M yofascial pain syndrome (MPS) is the most common cause of chronic pain. 1,2 It is seen in approximately 30% of patients in primary care clinics 3 and in 85% to 93% of patients in specialty pain centers. 2,4 To date, the diagnosis of MPS is a clinical one, with reliance on the clinician's ability to identify the presence of myofascial trigger points (MTrPs) through palpation. ...
Objectives
Myofascial pain syndrome (MPS) is the most common cause of chronic pain worldwide. The diagnosis of MPS is subjective, which has created a need for a robust quantitative method of diagnosing MPS. We propose that using a support vector machine (SVM) along with ultrasound (US) texture features can differentiate between healthy and MPS‐affected skeletal muscle.
Methods
B‐mode US video data were collected in the upper trapezius muscle of healthy (29) participants and patients with active (21) and latent (19) MPS, using an acquisition method outlined in previous works. Regions of interest were extracted and filtered to obtain a unique set of 917 images where texture features were extracted from each region of interest to characterize each image. These texture features were then used to train 4 separate binary SVM classifiers using nested cross‐validation to implement feature selection and hyperparameter tuning. The performance of each kernel was estimated on the data and validated through testing on a final holdout set.
Results
The radial basis function kernel classifier had the greatest Matthews correlation coefficient performance estimate of 0.627 ± 0.073 (mean ± SD) along with the largest area under the curve of 91.0% ± 3.0%. The final holdout test for the radial basis function classifier resulted in 86.96 accuracy, a Matthews correlation coefficient of 0.724, 88% sensitivity, and 86% specificity, validating our earlier performance estimates.
Conclusions
We have demonstrated that specific US texture features that have been used in other computer‐aided diagnostic literature are feasible to use for the classification of healthy and MPS muscle using a binary SVM classifier.
... The integrated hypothesis is one of the most widely accepted pathophysiological explanations of myofascial pain syndrome (MPS) (10,29). According to this hypothesis, an excessive secretion of ACh initiates a cascade of events leading to the formation of contraction knots. ...
Myofascial pain syndrome is one of the most common forms of muscle pain. In this syndrome pain is originated by the so-called trigger points, which consists of a set of palpable contraction knots in the muscle. It has been proposed that a high spontaneous neurotransmission may be involved in the generation of these contraction knots. To confirm this hypothesis, we exposed mouse muscles to an anticholinesterasic agent to increase the neurotransmision in the synaptic cleft in two different conditions, in vivo and ex vivo experiments. Using intracellular recordings a sharp increase in the spontaneous neurotransmission in the levator auris longus muscle and a lower increase in the diaphragm muscle could be seen. Likewise electromyography recordings reveal an elevated endplate noise in gastrocnemius muscle of treated animals. These changes are associated with structural changes such as abundant neuromuscular contracted zones observed by rhodaminated α-bungarotoxin and the presence of abundant glycosaminoglycan's around the contraction knots evidenced by Alcian PAS staining. In a second set of experiments we aimed at demonstrating that the increases in the neurotransmission reproduced most of the clinical signs associated to a trigger point. We exposed rats to the anticholinesterase agent neostigmine and 30 min. after we observed the presence of palpable taut bands, the echocardiographic presence of contraction knots and local twitch responses upon needle stimulation. In summary, we demonstrated that increased neurotransmission induced trigger points in both rats and mice and we evidenced glycosaminoglycan's around the contraction zones as a novel hallmark of this pathology.
... MTrPs can often be active, inducing spontaneous pain or latent, and painful only on deep palpation (Dommerholt, Bron, & Franssen, 2006). MTrPs are probably the most commonly encountered, nonetheless the most poorly recognized and undertreated components of nonarticular musculoskeletal pain disorders (Harden, Bruehl, Gass, Niemiec, & Barbick, 2000;Hendler & Kozikowski, 1993;Robert, 2007). ...
Background
Electrotherapeutic modalities have proven to be one of the best therapeutic options for myofascial pain syndrome, targeting the myofascial trigger points (MTrPs). Combined therapy (CT) is described with paucity in literature as the application of ultrasound (US) and electrical stimulating current concurrently and at the same site.
Aim
The aim was to compare between low‐frequency, high‐intensity burst transcutaneous electrical nerve stimulation CT (burst‐TENS‐CT) and medium‐frequency, low‐intensity amplitude modulated frequency CT (AMF‐CT) on upper trapezius active MTrPs (A‐MTrPs).
Participants and intervention
In this single‐blinded randomized controlled trial design, 70 participants with acute mechanical neck pain and at least two A‐MTrPs in the upper trapezius were simply and randomly allocated into three groups—the burst‐TENS‐CT, the AMF‐CT, or the sham‐CT control groups. All groups received three sessions per week for four consecutive weeks.
Outcome measures
Outcome measures included pressure pain threshold (PPT) using a digital electronic algometer and active cervical lateral flexion range of motion (ROM) using an iPhone Clinometer application. Data were collected prior to the first treatment and at the end of the 4‐week trial.
Results
There were statistically significant improvements in postintervention PPT and ROM values in both treatment groups (p < 0.0001). As for the sham‐US, no significant difference was found between the preintervention and postintervention values (p > 0.05). Bonferroni correction test revealed that there was a significant difference between all the three groups (p < 0.0001). Additionally, burst‐TENS‐CT yields a greater increase in PPT and ROM values (547% and 49.32%, respectively) than that of medium‐frequency AMF‐CT.
Conclusion
Within the scope of this study, both CT modalities were effective in increasing PPT and cervical lateral flexion ROM. Nonetheless, low‐frequency, high‐intensity burst‐TENS‐CT was shown to be superior over the medium‐frequency, low‐intensity AMF‐CT in terms of reducing pain sensitivity and increasing ROM.
... Myofascial pain syndrome (MPS) is one of the most common causes of chronic pain. 1,2 It has been reported in approximately 30% of patients seen in primary care clinics 3 and in 85% to 93% of patients in specialty pain centers. 2,4 There are approximately 9 million people suffering from myofascial pain in the United States alone, 5 and thus there are many more worldwide. ...
Objective-The objective of this study is to assess the discriminative ability of textural analyses to assist in the differentiation of the myofascial trigger point (MTrP) region from normal regions of skeletal muscle. Also, to measure the ability to reliably differentiate between three clinically relevant groups: healthy asymptomatic, latent MTrPs, and active MTrP. Methods-18 and 19 patients were identified with having active and latent MTrPs in the trapezius muscle, respectively. We included 24 healthy volunteers. Images were obtained by research personnel, who were blinded with respect to the clinical status of the study participant. Histograms provided first-order parameters associated with image grayscale. Haralick, Galloway, and histogram-related features were used in texture analysis. Blob analysis was conducted on the regions of interest (ROIs). Principal component analysis (PCA) was performed followed by multivariate analysis of variance (MANOVA) to determine the statistical significance of the features. Results-92 texture features were analyzed for factorability using Bartlett's test of sphericity, which was significant. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.94. PCA demonstrated rotated eigenvalues of the first eight components (each comprised of multiple texture features) explained 94.92% of the cumulative variance in the ultrasound image characteristics. The 24 features identified by PCA were included in the MANOVA as dependent variables, and the presence of a latent or active MTrP or healthy muscle were independent variables. Conclusion-Texture analysis techniques can discriminate between the three clinically relevant groups.
... MPS is clinically expressed by referred pain [7], limited range of motion in joints, and a local twitch response triggered by mechanical stimulation of certain muscular and fascial regions [9]. These focal hypersensitivity areas are known as myofascial trigger points (MTrPs) [2,8,10,11] and are associated with dysfunctional motor endplates [8,10,[12][13][14]. ...
Myofascial pain syndrome is characterized by pain and limited range of motion in joints and caused by muscular contracture related to dysfunctional motor end plates and myofascial trigger points (MTrPs). We aimed to observe the anatomical correlation between the clinically described MTrPs and the entry point of the branches of the inferior gluteal nerve into the gluteus maximus muscle. We dissected twenty gluteus maximus muscles from 10 human adult cadavers (5 males and 5 females). We measured the muscles and compiled the distribution of the nerve branches into each of the quadrants of the muscle. Statistical analysis was performed by using Student’s t -test and Kruskal-Wallis tests. Although no difference was observed either for muscle measurements or for distribution of nerve branching among the subjects, the topography of MTrPs matched the anatomical location of the entry points into the muscle. Thus, anatomical substract of the MTrPs may be useful for a better understanding of the physiopathology of these disorders and provide basis for their surgical and clinical treatment.
... Researches of various kinds of treatments show strong evidence that manual therapy has a positive effect on patients with long term low back dysfunction, but there is still no evidence for the best type of modality chosen (Harden et al., 2000). ...
... Myofascial pain syndrome is the most common cause of chronic pain. 2,3 It is seen in approximately 30% of primary care clinic patients 4 and in 85% to 93% of patients in specialty pain centers. 3,5 More than 50% of people who have myofascial pain syndrome continue to have pain 1 year after diagnosis. ...
Objectives:
Myofascial pain syndrome is one of the most common causes of chronic pain and is highlighted by the presence of myofascial trigger points. The current practice of diagnosing myofascial pain syndrome among clinicians involves manual detection of myofascial trigger points, which can be inconsistent. However, the detection process can be strengthened with the assistance of ultrasound (US). Therefore, this study aimed to characterize the upper trapezius by using quantitative techniques in healthy asymptomatic individuals with neck pain.
Methods:
Study participants were recruited on the basis of the inclusion and exclusion criteria established, and US images of the trapezius, along the axial and longitudinal orientations, were obtained. Each set was obtained by 2 investigators: experienced and inexperienced personnel.
Results:
Fifteen participants were recruited. The mean gray scale US echo intensity distribution obtained was 41.9. A paired t test of the global mean echo intensity value obtained for each image from the US operators did not show any significant difference (P = .77). A t test was performed, comparing the echo intensity of the group of patients with neck pain and healthy control participants, and the difference was found to be significant (P = .052). The median blob area was 2.71. The quartile range for the blob area was 1.72 for the 25th percentile to 4.90 for the 75th percentile.
Conclusions:
This study demonstrated that quantitative analysis of the echo intensity of US images can provide important information. However, further research is necessary to explore the relationships among sex, age, blob area, count, body mass index, regional anatomy, and extent of training or exercise of the particular muscle.
... Conversely, an active trigger point is frequently responsible for the presenting complaint. Despite the criticisms regarding MTrP theory (Quintner et al., 2014;Cohen and Quinter, 2008) and the poor reliability of MTrP manual palpation procedures (Lucas et al., 2009;Myburgh et al., 2008) many health professionals are currently educated in the treatment of myofascial pain syndrome (MPS) and the MPS diagnosis is accepted by the International Association for the Study of Pain (Harden et al., 2000). ...
Background:
The methodological quality of controlled clinical trials (CCTs) of physiotherapeutic treatment modalities for myofascial trigger points (MTrP) has not been investigated yet.
Objectives:
To detect the methodological quality of CCTs for physiotherapy treatments of MTrPs and demonstrating the possible increase over time.
Design:
Systematic review.
Methods:
A systematic search was conducted in two databases, Physiotherapy Evidence Database (PEDro) and Medicine Medical Literature Analysis and Retrieval System online (MEDLINE), using the same keywords and selection procedure corresponding to pre-defined inclusion criteria. The methodological quality, assessed by the 11-item PEDro scale, served as outcome measure. The CCTs had to compare at least two interventions, where one intervention had to lay within the scope of physiotherapy. Participants had to be diagnosed with myofascial pain syndrome or trigger points (active or latent).
Results:
A total of n = 230 studies was analysed. The cervico-thoracic region was the most frequently treated body part (n = 143). Electrophysical agent applications was the most frequent intervention. The average methodological quality reached 5.5 on the PEDro scale. A total of n = 6 studies scored the value of 9. The average PEDro score increased by 0.7 points per decade between 1978 and 2015.
Conclusions:
The average PEDro score of CCTs for MTrP treatments does not reach the cut-off of 6 proposed for moderate to high methodological quality. Nevertheless, a promising trend towards an increase of the average methodological quality of CCTs for MTrPs was recorded. More high-quality CCT studies with thorough research procedures are recommended to enhance methodological quality.
... Licht et al. recently demonstrated that some 'key' diagnostic criteria acc. to Simons and Travell [31] of myofascial trigger points could reliably be found by two different examiners in a smaller sample group [35]. Harden et al. presented 2000 a list of additional 31 signs and symptoms that are related to myofascial disorders [36]. ...
... El síndrome de dolor miofascial (SDM) se deine como un conjunto de síntomas sensoriales, motores y autonómicos causados por los puntos gatillo miofasciales (PGM) 1,2 . Un PGM es una zona hiperirritable en un músculo esquelético, asociada con un nódulo palpable y sensible, situada en una banda tensa de músculo. ...
Introduction: The technique of dry needling involves piercing the skin with a solid needle and
destroys an area of myofascial trigger points. Different types of needles and manipulations
could be a factor to consider for choosing the needle and its application.
Objective: To evaluate possible modiications of the tips of the needles used during the DN.
Material and methods: Three types of needles were analysed: 0.25 mm and 0.32 mm thick (Agu-
Punt®) and 0.25 mm (SEIRIN®) with two scanning electron microscopy (FEI Quanta 600 and JEOL
JSM 6360LV) to 2,000 magniications. The needles were evaluated in the following situations:
new unused needles; used without gloves; up to 10 insertions in skin; up to 40 insertions in
muscle; two to 10 impacts on bone. Occasionally microanalysis was performed by diffusion of RX
with an Oxford Instrument, Inca.
Results: New needles showed metallic particles on its surface; when needles were handled
without gloves, some dust particles were adhered at their surface; there were no alterations in
the morphology of the needles after 10 inserts in the skin or 40 inserts in the muscle; after colliding
with the scapula (2 and 10 impacts) only changes were obtained at the tip of a needle
depending on the operator. The microanalysis of the needles showed similar metallic composition
between different suppliers.
Conclusions: In this study, the tested needles do not show signiicant defects neither before nor
after clinical use by the technique of DN.
... A recent survey of physician members of the American Pain Society showed general agreement that MPS is a distinct syndrome. 4 Throughout the history of manual physical therapy,MPS and MTrPs have received little or no attention, although several studies have demonstrated that MTrPs are commonly seen in acute and chronic pain conditions,and in nearly all orthopaedic conditions. 5 Vecchiet and colleagues demonstrated that acute pain following exercise or sports participation is often due to acutely painful MTrPs. ...
... Myofascial pain is a clinical problem that has generated interest, debate and confusion for decades [1][2][3]. According to studies anywhere between 33 and 97 % of patients with musculoskeletal pain visiting physicians and manual therapists are diagnosed with myofascial pain syndrome (MPS) [4,5]. MPS is commonly misdiagnosed and overlooked by clinicians who are unfamiliar with this [6]. ...
Background
Myofascial pain is a common syndrome, which has not been studied extensively in the low back. Despite a variety of manual and instrument assisted interventions available, little work has targeted the possible effects of fast mechanical impulses on myofascial trigger points (MTrPs) on its sensitivity and electrical activity. The purpose of this experimental study was to quantify the immediate effect of one session of mechanical impulses to lumbar latent MTrPs and to normal muscle tissue with pressure pain threshold (PPT) and surface electromyography (sEMG) as outcome measures.
Methods
During the autumn of 2009, in 41 asymptomatic subjects between 17-40 years of age the lumbar musculature was searched for a latent MTrP by a trained clinician. Using 3 disposable pre-gelled electrodes bilaterally, sEMG was recorded continuously from muscle containing either latent or no MTrP. Both the trigger point group and control group received the intervention and were blinded to group allocation. The immediate effects of mechanical impulses were assessed by sEMG and PPT before and after intervention using Wilcoxon matched-pairs signed-ranks test, Mann–Whitney U test and paired t-tests.
Results
The PPT increased significantly across both groups (p < 0.01) after intervention. The proportionate increase (14.6 %) was comparable in both MTrP and control groups. The electrical activity on the MTrP side was not significantly higher in the MTrP group compared to the contralateral side. The decrease of resting electrical activity after intervention was significant in the MTrP group on the side of the latent MTrP (P = 0.001) as well as the contralateral side (p=0.022), and not significant in the control group on either side (p=0.33 and p=0.93).
Conclusion
In this study, the immediate effect of one session of mechanical impulses was associated with a significant increase in PPT for both groups and a significant decrease in the resting electrical activity of the lumbar muscles only in the MTrP group. It is unknown if these effects have clinical significance.
The practice of pain medicine has changed dramatically over the past few years. This practical and accessible evidence-based clinical handbook provides medical and nursing professionals with in-depth and up-to-date information on the various types of chronic pain, the underlying causes, and associated symptoms. Focused primarily on the management of chronic pain, the book covers the major chronic pain conditions in the head and neck, spine, and extremities. Also, it provides invaluable guidance on various pain management techniques, including medication, physical therapy, and psychological interventions. With this knowledge, healthcare professionals will be equipped to provide more effective and compassionate care, improve patients' quality of life, and reduce the risk of chronic pain and opioid dependence. An invaluable resource for pain medicine physicians, anesthesiologiests, primary care physicians, emergency medicine physicians, and nurse anaesthetists as well as those physicians preparing for US Board certification and recertification exams.
Actuality. According to various authors, hypertrophic scars are formed in 30% of cases after facial operations, in 35% causes of velopharyngeal insufficiency (VPI) are deforming scars in the soft palate area. Among the many known methods of regenerative therapy, the most effective is the introduction of platelet-rich plasma (PRP).Materials and methods. Performed examination and treatment of 11 children aged 4 to 17 years, including 6 children with hypertrophic scars after primary cheilorhynoplasty and 5 children with soft palate scarring after veloplasty. Clinical and laboratory examination of the scars was performed on a modified Vancouver scale, the results of Doppler ultrasound, MRI on the 8th and 15th day of application of PRP therapy.Results and Discussion. The analysis of the indicators revealed that before the plasma injection the scar values ranged from 10 to 13 points. According to Doppler imag-ing, tissue density in the scar area was hyperechogenic in 67% of cases, hypoechogenic in 33%. The mean linear size of the scar inmm was 9.4x3.01 (the area of the scar was 28.29mm²), the blood flow in the scars was not visu-alized, and in tangent tissues in 100% of cases, single loci of blood flow were recorded. 8 days after the first session of plasmotherapy, the total score of scar indicators was in the range from 8 to 10. The analysis of Doppler results showed a slight decrease in the linear size of the scar due to the thickness (by 0.5 mm), the average linear dimen-sions were equal to 9.4 × 2.51 mm. (the area of the scar was 23.59mm²); the enhancement of blood flow in the tangent tissues due to a slight increase in blood flow loci was visualized. After the second PRP session, all patients had an average score of 9. According to the results of Doppler ultrasound, the linear dimensions of the scar de-creased mainly due to thickness and amounted to 6.27x2.00 mm (area of the scar 12.54mm²). In 50% of cases, increased blood flow in the tangent tissues due to an increase in blood flow loci and the number of vessels.In 5 patients after veloplasty, clinically, mild mobility of the soft palate, ischemic mucous membrane was found. All children were diagnosed with a hyperintense signal (HU 438 ± 21.12) of scar tissue in the area of themuscu-lar aponeurosis of the soft palate, irregularly shaped with clear borders. After the first injection of PRP on 7th day, all children had a partial recovery of the color of the soft palate over the scar. MRI revealed a decrease in signal intensity to HU=352±15.71, scar borders became un-clear. The second injection of PRP into the scar tissue was performed after 7-8 days. Clinical and speech-therapy examination showed no significant change com-pared to the effect after the first injection. The signal in-tensity after the second injection was within HU=348±22.14, indicating statistical inaccuracy between them.Conclusions. There was a positive result of the use of in-jectable form of PRP therapy in hypertrophic scars of the skin and soft palate. The structureof scar tissue after PRP in the skin scar undergoes slight changes mainly due to the reduction of its thickness, the increase of blood flow loci and the number of vessels in the tissues. According to the received clinical, speech-therapy, MRI data, one in-jection of PRP is sufficient to reduce scar tissue density in children with VPI.Keywords.PRP-therapy, hypertrophic scars, maxillofa-cial area, children.
Objective:
Myofascial pain syndrome (MPS) is one of the most common causes of chronic pain and affects a large portion of patients seen in specialty pain centers as well as primary care clinics. Diagnosis of MPS relies heavily on a clinician's ability to identify the presence of a myofascial trigger point (MTrP). Ultrasound can help, but requires the user to be experienced in ultrasound. Thus, this study investigates the use of texture features and deep learning strategies for the automatic identification of muscle with MTrPs (i.e., active and latent MTrPs) from normal (i.e., no MTrP) muscle.
Methods:
Participants (n = 201) were recruited from Toronto Rehabilitation Institute, and ultrasound videos of their trapezius muscles were acquired. This new data set consists of 1344 images (248 active, 120 latent, 976 normal) collected from these videos. For texture analysis, several features were investigated with varying parameters (i.e., region of interest size, feature type and pixel pair relationships). Convolutional neural networks (CNN) were also applied to observe the performance of deep learning approaches. Performance was evaluated based on the classification accuracy, micro F1-score, sensitivity, specificity, positive predictive value and negative predictive value.
Results:
The best CNN approach was able to differentiate between muscles with and without MTrPs better than the best texture feature approach, with F1-scores of 0.7299 and 0.7135, respectively.
Conclusion:
The results of this study reveal the challenges associated with MTrP identification and the potential and shortcomings of CNN and radiomics approaches in detail.
Objective:
To conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.
Methods:
MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points", "trigger point", "myofascial trigger point", "myofascial trigger points", "myofascial pain" and "myofascial pain syndrome". The MeSH keywords were combined by using Boolean operators "OR"/"AND". All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least one active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.
Results:
Of 478 possibly relevant publications, 198 met our inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the six criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness", "referred pain" and "local twitch response" (n=28 studies, 22%).
Conclusions:
A noteworthy number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain and local twitch response were the three most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.
Registry:
This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.
Myofascial pain is considered one of the most frequent causes of pain. Simons reviewed the literature and indicated that in the practice of internal medicine about 30% of patients suffer from myofascial pain. Regardless of the underlying mechanism of trigger point origination, the treatment of MPS is usually directed to the trigger point in the palpable taut band aiming at reducing its sensitivity. Iontophoresis is non invasive, economical, less irritable and comfort to the patient than invasive method. Many authors stated that Lidocaine Iontophoresis is effective in decreasing musculoskeletal pain. It is well documented that direct current is also effective in reducing musculoskeletal pain and MTP, but how for the Lidocaine Iontophoresis is effective with respect to other treatment modalities on Myofascial trigger point is not known. So this study aimed to know the relative efficacy of 4% Lidocaine Iontophoretic treatment in patients having myofascial pain syndrome & to compare it to manual therapy treatment like Muscle energy techniques. 30 patients were selected and divided into two groups (n=15), namely Experimental Group (Iontophoresis + MET) & Control Group (only MET). The 2 × 3 ANOVA revealed that there was a main effect for time and group, also the main effect qualified to the interaction of time × group Post Hoc analysis revealed that the Experimental group had a significant improvement in VAS score, PPT and increased Contralateral side flexion ROM as compared to Control Group. So that it can be concluded that Iontophoresis with 4% Lidocaine to upper trapezius had an added effect in Reducing Pain and improving PPT & ROM of cervical spine in Myofascial Pain syndrome, then when the condition was treated with MET alone.
Keywords: Myofascial Pain Syndrome, trigger point, Iontophoresis, Lidocaine.
Purpose
Ultrasound is a non-invasive quantitative method to characterize sonographic textures of skeletal muscles. To date, there is no information available on the trapezius muscle. This study assessed the trapezius muscles of patients with myofascial pain compared with normal healthy participants.
Methods
The trapezius muscles of 15 healthy and 17 myofascial pain participants were assessed using B-mode ultrasound to obtain 120 images for healthy and 162 images from myofascial pain participants. Texture features such as blob area, count and local binary patterns (LBP) were calculated. Multi-feature classification and analysis were performed using principal component analysis (PCA) and MANOVA to determine whether there were statistical differences.
Results
We demonstrate the two principal components composed of a combination of LBP and blob parameters which explain 92.55% of the cumulative variance of our data set. In addition, blob characteristics were significantly different between healthy and myofascial pain participants.
Conclusion
Our study provides evidence that texture analysis techniques can differentiate between healthy and myofascial pain affected trapezius muscles. Further research is necessary to evaluate the nature of these differences.
Introduction: Myofascial release (MFR) is a form of manual therapy that involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function. MFR is being used to treat patients with a wide variety of conditions, but there is a scarcity of evidence to support its efficacy. Studies are emerging in this field with varying results and conclusions. Analysis of the recent research trials and reviews will be a better way to appraise the quality and reliability of such works.
Objective: This work attempts to analyse and summarise the evidence from three randomised controlled trials (RCTs) and one systematic review of the effectiveness of MFR on various neuromuscular conditions and pain.
Methodology: Effectiveness of MFR on tension type headache, lateral epicondylitis and chronic low back pain were the RCTs identified for the analysis. The systematic review selected analysed the published RCTs on MFR till 2014. The methodological qualities of the studies were assessed using the PEDro, Centre for Evidence-Based Medicine's (CEBM) Level of Evidence Scale, Risk of Bias (RoB) Analysis Tool and AMSTAR 2.
Results: The RCTs analysed in this study were of moderate to high methodological quality (PEDro scale), with higher level of evidence (CEBM scale) and less bias (RoB). The effectiveness of MFR on tension type headache (TTH) was the first among the studies with a moderate methodological quality (6/10 in PEDro), with a 2b level of evidence on the CEBM scale. The study proved that direct technique or indirect technique MFR was more effective than the control intervention for TTH. The second RCT studied MFR for lateral epicondylitis (LE). The study was of a moderately high quality on the PEDro scale (7/10) with a 1b- level in CEBM. The MFR was found more effective than a control intervention for LE in computer professionals. The RCT on chronic low back pain (CLBP) also scored 7/10 in the PEDro scale and 1b in the CEBM scale. This study confirmed that MFR is a useful adjunct to specific back exercises and more helpful than a control intervention for CLBP. All three RCTs stated the usage of self-report measures and underpowered sample size as the major limitations along with a performance bias reported in the TTH trial.
The systematic review demonstrated moderate methodological quality as per the AMSTAR 2 tool which analysed 19 RCTs for a result. The literature regarding the effectiveness of MFR was mixed in both quality and results. Omission of a risk of bias analysis was the major limitation of this review. The authors quoted that “MFR may be useful as either a unique therapy or as an adjunct therapy to other established therapies for a variety of conditions”.
Conclusion: Critical appraisal is an important element of evidence-based medicine to carefully and systematically examine research to judge its trustworthiness, its value and relevance in a particular context. This review concludes that the three RCTs and the systematic review analysed were completed with moderate to good quality as per various quality measures, but with reported methodological flaws and interpretation biases. These studies with the critical appraisal can act as ‘pavements’ on which high quality future MFR trials and evidence can be built on.
KEY WORDS: myofascial release, myofascial release therapy
Objectives:
The goal of this study was to assess agreement on signs and symptoms of myofascial pain for chiropractors, physicians, and registered massage therapists.
Methods:
337 healthcare practitioners participated in the survey. The questionnaire probed clinician agreement with the chosen signs and symptoms using a seven-point agreement scale (1-absolutely agree, 7-absolutely disagree). Agreement was assessed using intraclass correlation within chiropractor, physician, and registered massage therapist groups and across all groups. Descriptive statistics, including mean response values, were used to assess which signs or symptoms were most often associated with myofascial pain.
Results:
There was poor agreement within chiropractors, physicians, and registered massage therapists on the criteria that represent MPS. Physicians and massage therapists were in agreement on four and disagreed on two items. Chiropractors were in agreement on a different set of signs and symptoms relative to physicians and registered massage therapists, and they expressed neutrality on most statements in the questionnaire. Registered massage therapists were in most agreement amongst each other as a group (ICC=0.80) relative to chiropractors (ICC=0.59) and physicians (ICC=0.51).
Discussion:
Our results suggest that there is a lack of agreement within and between health care practitioner groups on the signs and symptoms that define myofascial pain syndrome. We suggest the demonstrated variability in diagnostic knowledge be remedied through the establishment and universal use of official validated criteria. Future research should focus on developing criteria specific to myofascial pain syndrome. Finally, knowledge translation strategies may be implemented to increase clinician knowledge of available criteria. This article is protected by copyright. All rights reserved.
There is good evidence supporting that people with fibromyalgia syndrome (FMS) exhibit central sensitization. The role of peripheral nociception is under debate in FMS. It seems that widespread pain experienced in FMS is considered multiple regional pains; therefore, several authors proposed that muscles play a relevant role in FMS. Trigger points (TrPs) have long been a contentious issue in relation to FMS. Preliminary evidence reported that the overall spontaneous pain is reproduced by referred pain from active TrPs, suggesting that FMS pain is largely composed of pain arising, at least partially, from TrPs. Finally, there is preliminary evidence suggesting that management of TrPs is able to modulate the CNS and is effective for reducing pain in FMS, although results are conflicting and future studies are clearly needed.
Recent work in our research consortium has raised internal validity concerns regarding the current IASP criteria for Complex Regional Pain Syndrome (CRPS), suggesting problems with inadequate sensitivity and specificity. The current study explored the external validity of these IASP criteria for CRPS. A standardized evaluation of signs and symptoms of CRPS was conducted by study physicians in 117 patients meeting IASP criteria for CRPS, and 43 patients experiencing neuropathic pain with established non-CRPS etiology (e.g. diabetic neuropathy, post-herpetic neuralgia). Multiple discriminant function analyses were used to test the ability of the IASP diagnostic criteria and decision rules, as well as proposed research modifications of these criteria, to discriminate between CRPS patients and those experiencing non-CRPS neuropathic pain. Current IASP criteria and decision rules (e.g. signs or symptoms of edema, or color changes or sweating changes satisfy criterion 3) discriminated significantly between groups (P
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
Although multidisciplinary pain programs have been demonstrated to be effective, the processes of improvement have yet to be clarified. Cognitive-behavioral models posit that improvement is due, in part, to changes in patient pain beliefs and coping strategies. To test the relationships between treatment outcome and changes in beliefs and coping strategies, 94 chronic pain patients completed measures of physical and psychological functioning, health care utilization, pain beliefs, and use of pain coping strategies at admission and 3 to 6 months after inpatient pain treatment. Improved functioning and decreased health care use were associated with changes in both beliefs and cognitive coping strategies. However, changes in some coping strategies, such as exercise and use of rest, were not associated with improvement.
To establish the reliability with which tenderness could be evaluated in patients with chronic myalgias, using dolorimetry and palpation.
Three blinded examiners using pressure dolorimetry and digital palpation compared 19 paired tender points and 8 paired control points in 4 matched groups of 6 patients with fibromyalgia (FM), myofascial pain, pain controls, and healthy controls.
Good interrater and test-retest reliability were found for dolorimetry scores. There were significant differences in tenderness ratings by dolorimetry between the diagnostic groups, with the patients with FM and myofascial pain having the greatest tenderness, the normals having the least tenderness, and the pain controls having tenderness levels midway between the patients with FM or myofascial pain and the normals. In all patients, control points had higher pain thresholds than tender points. One-third of patients with localized pain complaints demonstrated a significant relationship between region of clinical pain complaint and measured tenderness thresholds by dolorimetry. In ratings of tenderness by digital palpation, there was very good intrarater reliability over 26 of 27 paired points, and good interrater reliability at 75% of the points. One-half of patients with localized pain complaints demonstrated a significant relationship between region of clinical pain complaint and number of tender points by palpation.
Both dolorimetry and palpation are sufficiently reliable to discriminate control patients from patients with myofascial pain and FM, but may not discriminate patients with myofascial pain from those with FM. Neither method appears to correlate well with the location of the clinical pain complaint, regardless of diagnosis.
The prerequisite for relief of musculoskeletal pain includes the following: (1) Identify the immediate cause of symptoms. (2) Induce specific treatment that is different for each type of musculoskeletal or myofascial pain such as TSs/TrPs, muscle spasm, psychologic tension, deficiency of muscle strength and/or flexibility particularly affecting key postural muscles, postural deviations, or fibromyalgia. (3) The etiologic and perpetuating factors that had caused TrPs and/or spasm as well as the irritative foci that caused hyperirritability have to be identified and treated properly. (4) Preinjection blocks and needling with infiltration of the abnormal sensitive and tender areas are highly effective for immediate relief of pain as well as for long-term results as will be discussed in another article in this issue. (5) Sensitization from an irritative focus (tissue damage, inflammation, trigger point) has the tendency to spread inducing segmental sensitization. The diagnostic features of segmental sensitization were described. (6) The pentad of the vicious cycle, discopathy, radiculopathy, and paraspinal spasm is described. The role of paraspinal spasm may include narrowing of the neural foramina contributing or causing a nerve root compression. Relief of paraspinal spasm by blocks and injections frequently relieves radicular symptoms and signs.
Objectives: To review clinical literature concerning the prevalence, diagnostic criteria, and treatment of myofascial trigger points [TrPs] and to summarize a new understanding of their etiology. Findings: In three studies, the prevalence of myofascial TrPs among patients complaining of pain anywhere in the body ranged from 30% to 93%; among patients with chronic craniofacial pain, 55%; and for lumbogluteal pain, 21%. Among four studies of interrater reliability for five TrP diagnostic characteristics, untrained experienced examiners achieved unsatisfactory mean kappa values of 0.35 and 0.38, trained inexperienced examiners examiners a fai value of 0.49, and trained experience examiners a good mean kappa of 0.74. The highest mean kappa values were for spot tenderness, pain recognition, and palpable band [0.84-0.88]. A revision of previous injection technique more effectively inactivates the multiple active loci that are an essential part of a trigger point. Recent literature introduced two differing hypotheses for the basic of TrPs: 1. dysfunctional muscle spindles; 2. dysfunctional extrafusal neuromuscular junctions. Clinically, TrPs are found in the endplate zone. Electrophysiological investigations of TrPs reveals phenomena which indicate that the electrical activity of active loci arises from dysfunctional extrafusal motor endplates rather than from muscle spindles. Conclusions: Myofascial TrPs are a common cause of musculoskeletal pain. Reliable diagnostic examination requires both training and experience. Several considerations help one to decide which are the most suitable diagnostic criteria of myofascial TrPs under given circumstances. The characteristic electrical activity of myofascial TrPs most likely originates at dysfunctional endplates of extrafusal muscle fibers. This dysfunction appears to play a key role in the pathophysiology of TrPs.
Twenty-two patients with fibrositis, selected from a general medical outpatient population by a screening questionnaire and subsequent evaluation, were compared with age-, sex-, and clinic-matched patients without fibrositis. Although there was a high prevalence of musculoskeletal complaints in both groups, the fibrositis patients had a uniform constellation of symptoms, including axial pain, severe aching and stiffness, morning fatigue, and modulation by specific factors. They also had a higher incidence of tension headache and irritable bowel syndrome. The use of a dolorimeter demonstrated that fibrositis patients had many more areas of localized tenderness than control patients, but also that fibrositis patients did not have diffusely diminished pain threshold and tolerance. Using the criteria of this study, fibrositis appears to be a common and readily definable syndrome within the spectrum of soft tissue rheumatism.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in ⩾ 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
Chronic intractable benign pain (CIBP) is defined as non-neoplastic pain of greater than 6 months duration without objective physical findings and known nociceptive peripheral input. To test the CIBP concept, 283 consecutive chronic pain patients were examined independently by a neurosurgeon and physiatrist and only congruent physical findings were coded. Because they did not fit the CIBP definition, patients with the following primary treatment diagnoses were eliminated: degenerative disease of the spine and spinal stenosis; degenerative disease of the hips; radiculopathy; malignancy; deafferentation pain; and miscellaneous. Eliminated, also, were patients with any one finding indicative of a root compression syndrome, leaving 90 low back and 34 neck patients. These patients had abnormal physical findings in 7 categories: tender points/trigger points; decreased ranges of motion in back or neck; non-anatomical sensory loss; rigid musculature; decreased range of hip motion; gait disturbance; and miscellaneous non-neurologic signs. Low back CIBP patients had the following distribution among the 7 categories: 0% had findings of all 7; 1.1% had 6; 13.3% had 5; 24.4% had 4; 25.6% had 3; 26.7% had 2; 8.9% had 1; and 0% had none. Neck CIBP patients, in which only the first 4 categories of physical findings were applicable had the following distribution: 2.9% had 4; 41.2% had 3; 35.3% had 2; 20.6% had 1; and 0% had none. It was concluded that CIBP patients do have abnormal physical findings indicative of musculoskeletal disease: possibly fibrositis and/or specific myofascial syndromes, as sources of peripheral nociception. These findings question the validity of the CIBP concept and point to the need for a careful, all-inclusive physical examination as a basic initial requirement in the classification of chronic pain patients.
Myofascial pain syndrome (MPS) is a common but misunderstood muscular pain disorder involving pain referred from small, tender trigger points within myofascial structures in or distant from the area of pain. Misdiagnosis or inadequate management of this disorder after onset may lead to development of a complex chronic pain syndrome. A review of the clinical characteristics of 164 patients whose chief complaints led to the diagnosis of MPS revealed that these patients had (1) tenderness at points in firm bands of skeletal muscle that were consistent with past reports, (2) specific patterns of pain referral associated with each trigger point, (3) frequent emotional, postural, and behavioral contributing factors, and (4) frequent associated symptoms and concomitant diagnoses.
Increasing recognition of the fibromyalgia syndrome together with concerns about limitations of currently available criteria led most centers engaged in fibromyalgia research in Canada and the United States to undertake a multicenter effort to define epidemiologically correct criteria for the diagnosis of fibromyalgia. Five hundred fifty-eight consecutive patients (293 with fibromyalgia and 265 controls) were recruited from 16 private practice and university centers. The study used training sessions to increase interrater reliability, and included methods to determine reliability of examination and historical data. Standardized definition and methods of data acquisition by independent, blinded assessors were employed.
Fibrositis (fibromyalgia) is a common disorder, but is often not considered or diagnosed by clinicians. It is characterized by widespread musculoskeletal pain and aching, disturbed sleep, fatigue, morning stiffness, and local tenderness. The presence of multiple (seven or more) tender points and widespread pain or aching are necessary and sufficient conditions for diagnosis. Fibrositis occurs in a "primary" form, but most commonly in association with other rheumatic diseases where it is a concomitant condition. The designation "myofascial pain syndrome" has replaced older concepts of localized fibrositis, and is considered a separate entity.
The essential symptoms of fibrositis—widespread aching and pain, disturbed sleep, morning stiffness, and fatigue—are common in both rheumatic and nonrheumatic patients. But the essential sign of fibrositis—widespread local tenderness over specific anatomic sites (“tender points”)—is rare in any patients except those with fibrositis. Clinical criteria for the diagnosis of fibrositis rely heavily on a high tender point count in the presence of characteristic fibrositic symptoms. Multiple tender points are uncommon in normal subjects and in those with rheumatic and nonrheumatic disorders. The tender point count thus also serves to distinguish fibrositis from other musculoskeletal diseases.
To assess the ability of the International Association for the Study of Pain Complex Regional Pain Syndrome (CRPS) diagnostic criteria and associated features to discriminate between CRPS patients and patients with painful diabetic neuropathy.
Prospective assessment of signs and symptoms in a series of CRPS and diabetic neuropathy patients.
University of Washington Multidisciplinary Pain Center.
A consecutive series of 18 CRPS patients and 30 diabetic neuropathy patients.
Patients completed a 10-item patient history questionnaire assessing symptoms of CRPS prior to medical evaluation. The evaluating physician completed a 10-item patient examination questionnaire assessing objective signs of CRPS.
The analyses conducted were designed to test the ability of CRPS signs and symptoms and associated features to discriminate between CRPS patients and diabetic neuropathy patients.
Data analysis suggested that CRPS decision rules may lead to overdiagnosis of the disorder. Diagnosis based on self-reported symptoms can be diagnostically useful in some circumstances. The addition of trophic tissue changes, range of motion changes, and "burning" quality of pain did not improve diagnostic accuracy, but the addition of motor neglect signs did. Test of a CRPS scoring system resulted in improved accuracy relative to current criteria and decision rules.
Poorly understood disorders lacking prototypical signs/symptoms and diagnostic laboratory testing must rely on the development of reliable diagnostic guidelines. The results of this study should assist in the further refinement of the CRPS diagnostic criteria.
Traumatic fibromyositis is not an inflammation; there is no fever, leukocytosis or increased sedimentation rate; electrical characteristics and serum enzyme levels are within normal limits, and there are no observable pathologic alterations, although they have been carefully searched for. Recent attempts to express the effects of muscular sprain or strain as a biochemical disturbance expressed in an unusual pattern of lactate dehydrogenase isoenzymes appear not only to be technically flawed but inconsistent with results of conventional enzyme studies on other muscle and interstitial inflammations. In the author's view, "traumatic" fibromyositis is no more than a verbal construct arrived at by adding an adjectival modifier to the old terms for idiopathic rheumatic disorders. An examination of the evolution of the concept of traumatic fibromyositis shows that it lacks validity as a clinical diagnosis and ought to be abandoned.
This investigation evaluated the diagnostic value of medical thermology for the documentation of myofascial trigger points. Previous investigators have suggested that circumscribed 'hot spots' reflect the thermal activity of trigger points. A total of 365 patients participated in the four separate experiments. Upper back trigger points were isolated via palpation. A separate thermographic examination, specific to that experiment, was conducted by a technologist who was blind to the presence or absence of trigger points. The first experiment examined the Swerdlow-Dieter protocol. Fifty percent of the subjects with trigger points demonstrated hot spots. Over 60% of patients without trigger points exhibited hot spots. Chi-square analysis determined that there was no significant difference between these two groups. The majority of hot spots were unrelated to trigger point location. The second experiment evaluated the protocol suggested by Fisher. Hot spots were evident in the majority of subjects, regardless of whether they possessed trigger points. The third experiment investigated hot spot persistence by adapting the Weinstein-Weinstein alcohol spray protocol. Chi-square analysis found no significant difference between the effect which spray had on the hot spots of patients with or without trigger points. Following a post-spray machine adjustment, the majority of pre-spray hot spots could be reproduced. The final experiment used a pressure threshold meter (PTM) to evaluate the number of kilograms pressure a patient's hot spot could comfortably sustain in comparison to the opposite location on the back. Using the t test, no significant difference was found between the kilograms pressure withstood by hot spot and non-hot spot regions.(ABSTRACT TRUNCATED AT 250 WORDS)
The criteria for performing a diagnosis of myofascial pain syndromes caused by trigger points (TrPs) are defined and the clinical features of pain and related phenomena due to these syndromes are examined together with the sensory modifications of the parietal tissues at TrPs and target level in the case of both active and latent TrPs. The factors presumably responsible for the occurrence of TrPs in myofascial structures are then considered, with particular emphasis on the microtraumatic event caused by biomechanical alterations during movement, evaluated by the analysis of the ground-foot reaction. With this respect, some examples of myofascial pain syndromes of the lower limbs are reported in which the correction of these alterations, performed via dynamic orthosis, produces a long-lasting remission of the subjective and objective symptomatology.
The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct in treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication.
Twenty patients with fibrositis and 19 patients with myofascial pain syndrome were compared with regard to pain levels, sleep quality, general pain threshold and localized pain responsiveness at fibrositic tender points. Patients with fibrositis had significantly lower pain responsiveness (p less than 0.01), lower pain threshold (p less than 0.05) and higher pain levels (p less than 0.05) than patients with myofascial pain syndrome when differences in age between the groups were controlled. No significant difference was found for sleep quality. Regional pain levels influenced local measures of pain sensitivity. A discriminant function, developed on the 4 main study variables, resulted in an almost 80% correct classification to groups.
Two basic diagnostic features of myofascial trigger points (TPs), namely, local tenderness and alteration of tissue consistency (such as in taut bands, muscle spasm), can be documented quantitatively by simple hand-held instruments. A pressure threshold meter (algometer) assists in location of TPs and their relative sensitivity. A side-to-side difference exceeding 2kg in comparison with normal values indicates pathologic tenderness. The effect of treatment can be quantified. Pressure tolerance, measured over normal muscles and shin bones, expresses pain sensitivity. Myopathy is suspected if muscle tolerance drops below bone tolerance. Tissue compliance measurement documents objectively and quantitatively alteration in soft tissue consistency. Muscle spasm, tension, spasticity, taut bands, scar tissues, or fibrositic nodules can be documented. The universal clinical dynamometer is used as part of a physical examination to quantify weakness. Thermography (heat imaging) demonstrates discoid shaped hot spots over TPs. Muscle activity, spasm, or contraction is visualized as increased heat emission in the shape of the active muscle.
The plasma myoglobin concentration was measured before and after massage of 26 patients with myofascial pain. Twenty-one patients had a successful treatment and a significant increase was observed in the plasma myoglobin concentration (median 125 micrograms/l, range 35-439) within a maximum of 2 hours after the first massage treatment (p less than 0.0001). A positive correlation was found between the degree of muscle tension and pain, and the increase in plasma myoglobin concentration. After repeated massage treatment a gradual decline in the increase in plasma myoglobin concentration could be demonstrated parallel to a reduction in the muscle tension and pain. Five patients did not benefit from massage treatment and no significant increase in the myoglobin in plasma was measured. These patients were in pain and had a high degree of muscle tension. The observed increase in myoglobin in plasma after massage indicates a leak of myoglobin from the muscle fibres in 21 patients, whose myofascial pain seem to be linked with a muscle fibre disease. It is suggested that 5 patients with the same muscle symptoms have another, still unknown muscle disease.
The essential symptoms of fibrositis--widespread aching and pain, disturbed sleep, morning stiffness, and fatigue--are common in both rheumatic and nonrheumatic patients. But the essential sign of fibrositis--widespread local tenderness over specific anatomic sites ("tender points")--is rare in any patients except those with fibrositis. Clinical criteria for the diagnosis of fibrositis rely heavily on a high tender point count in the presence of characteristic fibrositic symptoms. Multiple tender points are uncommon in normal subjects and in those with rheumatic and nonrheumatic disorders. The tender point count thus also serves to distinguish fibrositis from other musculoskeletal diseases.
The clinical manifestations, laboratory findings, and treatment results of 118 patients with fibromyalgia followed up by one investigator were compared with those of other recent reports. The history of this syndrome and recent efforts to establish diagnostic criteria and to understand underlying pathophysiologic mechanisms were studied. A practical, noninvasive office-based evaluation and conservative treatment approach were developed, determined by an understanding of the natural history of this common but controversial disorder.
Pressure threshold is the minimal pressure (force) which induces pain. The pressure threshold meter (PTM) is a force gauge with a rubber disc of 1 cm2 surface. The instrument has been proven to be useful in clinical practice for quantification of deep muscle tenderness. Trigger points, fibrositis, myalgic spots, activity of arthritis as well as assessment of sensitivity to pain can be diagnosed by PTM. This study therefore established standards for pressure threshold as well as the reproducibility and validity of measurement in 24 male and 26 female normal volunteers at 9 sites. Muscles frequently afflicted by trigger points were examined. The deltoid was chosen as a reference since it is rarely a site for trigger points. Comparison of corresponding muscles on opposite sides failed to demonstrate significant differences (except for 1 muscle in females). These identical results obtained over muscles of opposite sides proved the excellent reproducibility and validity of pressure threshold measurement. Results serve as a reference for clinical diagnosis of abnormal tenderness and for documentation of treatment results. The sensitivity of individual muscles varies. Therefore the results presented should be kept in mind when diagnosis of pathological tenderness by palpation is attempted.
Electromyographic (EMG) recordings of the local twitch response in sixteen subjects with pain from active myofascial trigger points in the upper trapezius muscle were examined and compared with recordings from the contralateral normal muscle bands in the same individual. Needle electromyography and a specific reproducible snapping palpation technique were used to elicit and record the local twitch response. The mean value for the EMG recordings of bands with trigger points versus the normal muscle bands using the visual scoring method were 3.81 and .81 respectively. Mean values for the EMG recordings of muscle bands with trigger points versus the normal muscle using the spike counting method were 31.81 and 8.75 respectively. Both results were statistically compared using student's t-test. The motorunit electrical activity of the bands with trigger points was found to be significantly higher (p less than or equal to 0.001) than that of the normal muscle.
Dental patients were classified by experienced dentists as MPD or non-MPD patients. Apart from the symptoms often used as criteria for such a classification, there is a broad range of symptoms and patient characteristics associated with MPD. Because of procedural and methodologic problems, little is known about the strength of these associations. Because reliable knowledge about symptoms and characteristics of MPD is needed for MPD etiology and for adequate treatment evaluation, the present study tried to establish which subjective signs and symptoms differentiate MPD from non-MPD patients. Results of a questionnaire show that 10 items classified 86% of the patients correctly. Among them, restricted mouth opening and sounds at jaw movement had the highest discriminative power. Pain in the jaw area also showed a highly significant difference between the patient groups. When patient selection is based on these criteria, approximately the same patient groups are obtained by a time-consuming dental examination and by a low-cost questionnaire. Results also showed that reported oral habits such as chewing on hard or tough objects and lip-tongue-cheek biting do not differentiate the two groups. Symptoms related to ears and eyes discriminate the groups only marginally. Sleep-related symptoms, with awakening with stiff or painful jaws as the most important item, differentiate patients in a more substantial way. The suggestion from a great number of studies that stress and tension are etiologic factors in MPD is not supported by the present results.(ABSTRACT TRUNCATED AT 250 WORDS)
Twenty-two patients with fibrositis, selected from a general medical outpatient population by a screening questionnaire and subsequent evaluation, were compared with age-, sex-, and clinic-matched patients without fibrositis. Although there was a high prevalence of musculoskeletal complaints in both groups, the fibrositis patients had a uniform constellation of symptoms, including axial pain, severe aching and stiffness, morning fatigue, and modulation by specific factors. They also had a higher incidence of tension headache and irritable bowel syndrome. The use of a dolorimeter demonstrated that fibrositis patients had many more areas of localized tenderness than control patients, but also that fibrositis patients did not have diffusely diminished pain threshold and tolerance. Using the criteria of this study, fibrositis appears to be a common and readily definable syndrome within the spectrum of soft tissue rheumatism.
Detailed clinical study of 50 patients with primary fibromyalgia and 50 normal matched controls has shown a characteristic syndrome. Primary fibromyalgia patients are usually females, aged 25-40 yr, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas and numbness. Physical examination is characterized by presence of multiple tender points at specific sites and absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day(worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism patients have little fluctuation, if any, and are modulated by emotional rather than physical factors. In psychogenic rheumatism, there is diffuse tenderness rather than tender points at specific sites. Laboratory tests and roentgenologic findings in primary fibromyalgia are normal or negative. Primary fibromyalgia should be suspected by the presence of its own characteristic features, and not diagnosed just by the absence of other recognizable conditions. This study has also shown that primary fibromyalgia is a poorly recognized condition. Patients were usually seen by many physicians who failed to provide a definite diagnosis despite frequent unnecessary investigations. A guideline for diagnosis of primary fibromyalgia, based upon our observations, is suggested. Management is usually gratifying in these frustrated patients. The most important aspects are a definite diagnosis, explanation of the various possible mechanisms responsible for the symptoms, and reassurance regarding the benign nature of this condition. A combination of reassurance, nonsteroidal antiinflammatory drugs, good sleep, local tender point injections, and various modes of physical therapy is successful in most cases.
The presence of a trigger point is essential to the myofascial pain syndrome. This study centres on identifying clearer criteria for the presence of trigger points in the quadratus lumborum and gluteus medius muscle by investigating the occurrence and inter-rater reliability of trigger point symptoms. Using the symptoms and signs as described by Simons' 1990 definition and two other former sets of criteria, 61 non-specific low back pain patients and 63 controls were examined in general practice by 5 observers, working in pairs. From the two major criteria of Simons' 1990 definition only 'localized tenderness' has good discriminative ability and inter-rater reliability (kappa > 0.5). This study does not find proof for the clinical usefulness of 'referred pain', which has neither of these two abilities. The criteria 'jump sign' and 'recognition', on the condition that localized tenderness is present, also have good discriminative ability and inter-rater reliability. Trigger points defined by the criteria found eligible in this study allow significant distinction between non-specific low back pain patients and controls. This is not the case with trigger points defined by Simons' 1990 criteria. Concerning reliability there is also a significant difference between the two different criteria sets. This study suggests that the clinical usefulness of trigger points is increased when localized tenderness and the presence of either jump sign or patient's recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius.
The clinical phenomenon of the MTrP is accessible to any clinician who takes the time to learn to palpate skeletal muscle gently and carefully, and who is willing to learn the functional anatomy necessary to understand the regional spread of MTrPs through functional muscle units (Travell and Simons, 1992). Yet despite the years of clinical study of MPS, the pathophysiology of the central feature, the trigger point, has remained elusive. Many investigators have contributed to the general understanding of the mechanisms of pain perception, but we owe a particular debt of gratitude to Dr Seigfried Mense of Heidelberg for his pursuit of the study of pain originating in muscle lesions. However, Dr Mense would be the first to caution us against the direct transference of the results obtained with an inflammatory lesion produced in the experimental animal to the pain of MTrPs in the clinic patient. Notwithstanding that, researchers in the field of pain have given us an understanding of the basis for the hyperalgesia, allodynia and the previously difficult-to-understand finding of referred pain zones that we see daily in our patients. Finally, the interesting initial observations of Hubbard and Berkoff (1993), suggesting that the muscle spindle may be associated with the trigger point, open yet another door in our understanding of the nature of MPS.
Fibromyalgia syndrome is generally taken to denote a clinical state of widespread musculoskeletal pain, stiffness, and fatigue but its pathophysiology, physical and psychological, is unknown, and the nature of the diagnostically mandatory "tender points" remains obscure. Diagnostic criteria convey no pathophysiological insight and they have been "validated" via a circular argument in which the evidence on which the construct is based is taken as proof of its veracity. The concept of fibromyalgia syndrome is valid only in the sense that it includes all possibilities. An alternative approach to this very real clinical presentation is via secondary hyperalgesia.
Monopolar needle electromyogram (EMG) was recorded simultaneously from trapezius myofascial trigger points (TrPs) and adjacent nontender fibers (non-TrPs) of the same muscle in normal subjects and in two patient groups, tension headache and fibromyalgia. Sustained spontaneous EMG activity was found in the 1-2 mm nidus of all TrPs, and was absent in non-TrPs. Mean EMG amplitude in the patient groups was significantly greater than in normals. The authors hypothesize that TrPs are caused by sympathetically activated intrafusal contractions.
During a 27-month recruitment period, we identified 146 individuals with multiple sclerosis (MS) who have a twin. A single clinician interviewed and examined 105 pairs of twins, and we confirmed zygosity using minisatellite probes. Including two suspected cases, 11 of 44 (25%) monozygotic twin pairs were concordant compared with two of 61 (3%) dizygotic twin pairs--two of 33 (6%) like-sexed and zero of 28 (0%) opposite-sexed. MRI was performed in 64 of 105 co-twins, and showed abnormalities consistent with demyelination in 13% of monozygotic and 9% of dizygotic co-twins who were clinically unaffected. These findings are similar to the results of most previous studies of MS in twins in which zygosity was not unequivocally established and where the majority of clinically unaffected co-twins were not studied by MRI; the difference in concordance rates in monozygotic and dizygotic twins indicates a significant genetic component in the etiology of MS.
This paper reviews the development of diagnostic criteria for the psychiatric disorders in order to provide a model for the development of classification of headache. The strengths and weaknesses of the current psychiatric classification system, and procedures that have been instituted to strengthen the next version of the classification are described. The problems that characterized the successive versions of the criteria are highlighted in order to stimulate future developments of diagnostic criteria for headache syndromes. Recommendations for application of these principles to headache classification are presented.
Myofascial pain syndromes (MPS) occur commonly in the community. Treatment by injection of local anaesthetic has met with variable success. We studied 50 out-patients with chronic localized MPS in order to find baseline correlates related to response to treatment. Data collected included sociodemographic and clinical histories as well as psychometric measures of self-efficacy, health locus of control and illness behaviour. Pretreatment pain intensity and scores on the Denial scale of the Illness Behavior Questionnaire (IBQ) were found to be associated with an immediate improvement in pain, while scores on the Affective Inhibition scale of the IBQ were associated with pain relief lasting up to 24 hours. The immediate response was not predictive of the duration of the effect of the treatment. This study shows that the severity of the pain and its role as part of a psychological coping strategy are related to the response to local treatment of MPS.
The aim of the present study was to investigate the stimulus-response function for pressure versus pain in patients with myofascial pain. Forty patients with chronic tension-type headache and 40 healthy controls were examined. Tenderness in 8 pericranial muscles and tendon insertions was evaluated by manual palpation with a standardized evaluated methodology. Thereafter, a highly tender muscle and a largely normal muscle were palpated with 7 different pressure intensities using a palpometer, and the induced pain was recorded by the subjects on a visual analogue scale blinded for the observer. Pericranial myofascial tenderness was considerably higher in patients than in controls (P < 0.00001). The stimulus-response function recorded from normal muscle was well described by a power function. From highly tender muscle, the stimulus-response function was displaced towards lower pressures and, more importantly, it was linear, i.e., qualitatively different from normal muscle. Our results demonstrate for the first time that nociceptive processes are qualitatively altered in patients with chronic myofascial pain and suggest that myofascial pain may be mediated by low-threshold mechanosensitive afferents projecting to sensitized dorsal horn neurons. Further investigations of these mechanisms may lead to an increased understanding and better treatment of these common and often incapacitation pain disorders.
The myofascial trigger point (MTrP) is the hallmark physical finding of the myofascial pain syndrome (MPS). The MTrP itself is characterized by distinctive physical features that include a tender point in a taut band of muscle, a local twitch response (LTR) to mechanical stimulation, a pain referral pattern characteristic of trigger points of specific areas in each muscle, and the reproduction of the patient's usual pain. No prior study has demonstrated that these physical features are reproducible among different examiners, thereby establishing the reliability of the physical examination in the diagnosis of the MPS. This paper reports an initial attempt to establish the interrater reliability of the trigger point examination that failed, and a second study by the same examiners that included a training period and that successfully established interrater reliability in the diagnosis of the MTrP. The study also showed that the interrater reliability of different features varies, the LTR being the most difficult, and that the interrater reliability of the identification of MTrP features among different muscles also varies.
Myofascial pain syndromes of the upper extremity are common causes of pain that may follow trauma and are associated with acute or chronic musculoskeletal stress. The syndromes are characterized by the presence of the myofascial trigger point, a physical finding that is reliably identified by palpation. Local and referred pain are hallmarks of the syndrome, and the referred pain patterns may mimic such conditions as radiculopathy and nerve entrapment syndromes. Treatment is directed toward inactivating the myofascial trigger point, correcting underlying perpetuating factors, and restoring the normal relationships between the muscles of the affected functional motor units.