Article

Myofascial Trigger Points in Neck and Shoulder Muscles and Widespread Pressure Pain Hypersensitivtiy in Patients With Postmastectomy Pain

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Abstract

To describe the presence of widespread pressure pain hyperalgesia and myofascial trigger points (TrPs) in neck and shoulder muscles in patients with postmastectomy pain. Twenty-nine women (mean age: 50±8 y) with postmastectomy pain and 23 matched healthy controls (mean age: 50±9 y) participated. Pressure pain thresholds (PPT) were bilaterally assessed over the C5-C6 zygapophyseal joint, the deltoid muscle, the second metacarpal, and the tibialis anterior muscle. TrPs in the upper trapezius, suboccipital, levator scapulae, sternocleidomastoid, scalene, infraspinatus, and pectoralis major muscles were explored. TrPs were considered active if the local and referred pain reproduced symptoms and the patient recognized the pain as familiar. Twenty-five (86%) patients reported neck pain whereas 20 (69%) patients showed shoulder/axillary pain. The results showed that PPT levels were significantly decreased bilaterally over the C5-C6 zygapophyseal joint, deltoid muscle, second metacarpal, and tibialis anterior muscle in patients with postmastectomy pain as compared with controls (all sites, P<0.001). No significant differences in the magnitude of PPT decrease between sites were found (P=0.222). The mean number of active TrPs for each woman with postmastectomy pain was 5.4±1.8. Healthy controls only had latent TrPs (0.5±0.6). Patients with postmastectomy pain showed a greater number of TrPs than controls (P<0.001). In all muscles, there was significantly more active TrPs in patients with postmastectomy pain as compared with controls (P<0.001). Active TrPs in the pectoralis major (n=27, 93%), infraspinatus (n=23, 79%), and upper trapezius (n=19, 65%) muscles were the most prevalent in the affected side in the postmastectomy group. The number of active TrPs was positively correlated with neck (rs=0.392, P=0.036) and shoulder/axillary (rs=0.437, P=0.018) pain intensity. Our findings revealed bilateral widespread pressure pain hypersensitivity in patients with postmastectomy pain. In addition, the local and referred pain elicited by active TrPs reproduced neck and shoulder/axillary complaints in these patients. These results suggest peripheral and central sensitization in patients with postmastectomy pain.

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... The combination of surgery and radiochemotherapy can lead to peripheral sensitization through the activation of nociceptors on A-delta and C fibres [21,22]. Central sensitization, as evidenced by local and widespread pressure hypersensitivity and hyperalgesia, has been investigated in survivors of breast [23] and colon [24] cancers, and when present, it is described to worsen perceived pain [25,26]. However, to our knowledge, no studies have investigated the peripheral and central sensitization processes that survivors of HNC (sHNC) may experience or its relationship with the presence of myofascial TrPs. ...
... Since neck dissection involves the sternocleidomastoid muscle, it may be the most affected in this respect following such surgery. Similar results were found in patients with postmastectomy pain, in whom the affected pectoralis major muscle had the largest number of active TrPs [23]. This suggest that surgery may activate TrPs and therefore increase the myofascial pain experiences in cancer survivors. ...
... The PPT of this muscle has previously been used as a distant point in order to provide stronger evidence of central sensitization. Similar differences were obtained in an earlier study comparing patients with breast cancer and healthy controls (40% lower PTT in the patients) [23]. This difference between sHNC and breast cancer patients suggests central sensitization is stronger in sHNC. ...
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Article
Purpose Medical treatment for head and neck cancer may induce the presence of inflammation, pain, and dysfunction. The purpose of the current study was to assess the presence of myofascial trigger points (TrPs) and their relationship with widespread pressure hypersensitivity and hyperalgesia in survivors of head and neck cancer (sHNC). Methods TrPs and pressure-pain thresholds (PPTs) were quantified in different muscles/joints in the head and neck of 30 sHNC (59.45 ± 13.13 years) and 28 age- and sex-matched controls (58.11 ± 12.67 years). Results The sHNC had more TrPs in all muscles on the affected side (p < 0.05) than did the healthy controls, and in the temporalis, masseter, and suboccipitalis muscles on the unaffected side (p < 0.05). They also had lower PPTs in all places (p < 0.05) except for the temporalis muscle (p = 0.114) and C5-C6 joint (p = 0.977). The intensity of cervical pain correlated positively with the presence of upper trapezius TrPs. Conclusions sHNC suffering cervical and/or temporomandibular joint pain have multiple active TrPs and experience widespread pressure hypersensitivity and hyperalgesia, suggestive of peripheral and central sensitization.
... Pain in breast cancer is classified into inflammatory/nociceptive pain (caused by damage to tissue, bone, muscle, or connective tissue) or neuropathic pain (caused by disease or lesions involving the nerves) [10]. However, at the latter stage of breast cancer treatment, when the local effects of the different treatment modalities should have disappeared, the primary causes of pain may be overshadowed by sensitization of the central nervous system in a subgroup of breast cancer survivors [9,11,12]. In a recent report, Leysen et al. indicated that due to the nature of the disease and the multimodal treatment, breast cancer patients are often exposed to a mixture of nociceptive, neuropathic, and/or central sensitization (CS) pain, also called mixed pain [13]. ...
... According to the International Association for the Study of Pain, CS is defined as "increased responsiveness of the nociceptive neurons in the central nervous system to normal or subthreshold afferent input" [14]; CS is operationally defined as the amplification of neural signaling within the central nervous system that elicits pain hypersensitivity [15]. There has been increasing evidence suggesting the influence of CS, such as reduction in the pain threshold and widespread pressure-pain hyperalgesia, on persistent pain in breast cancer survivors [11,12,16]. Although these studies evaluated pain hypersensitivity, the main aspect of CS, through the pressure-pain threshold and temporal summation measured using Quantitative Sensory Testing (QST) [11,12,16], QST is a burden for clinicians because of associated high cost, complexity, and time-consuming quality [9]. ...
... There has been increasing evidence suggesting the influence of CS, such as reduction in the pain threshold and widespread pressure-pain hyperalgesia, on persistent pain in breast cancer survivors [11,12,16]. Although these studies evaluated pain hypersensitivity, the main aspect of CS, through the pressure-pain threshold and temporal summation measured using Quantitative Sensory Testing (QST) [11,12,16], QST is a burden for clinicians because of associated high cost, complexity, and time-consuming quality [9]. Recently, the Central Sensitization Inventory (CSI) was proposed as an alternative method and a comprehensive screening tool for the evaluation of CS-related symptoms [17,18]. ...
Article
Background In breast cancer survivors, multiple risk factors for health-related quality of life (HRQoL) and chronic pain, including cancer treatment-related factors, psychosocial factors, and central sensitization (CS), have been suggested; however, there has been no comparative study between breast cancer survivors with and without pain. This study aimed to compare the demographic characteristics, psychological factors, and CS-related symptoms between breast cancer survivors with pain, those without pain, and healthy controls, and to investigate the relationships of these factors with HRQoL. Methods We conducted a cross-sectional survey of 218 women, including patients who underwent breast cancer surgery and adjuvant therapy and healthy women. Results Patients were divided into the pain group (n = 42), without-pain group (n = 51), and healthy group (n = 47); thus, among breast cancer survivors, 45% reported chronic pain. The proportion of participants who received breast cancer treatments, such as axillary lymph node dissection and chemotherapy, was higher in the pain group than in the without-pain group (p < 0.05). The Central Sensitization Inventory (CSI) and psychosocial factors in the pain group were higher than those in the without-pain group and healthy group (p < 0.01). The CSI and PCS showed larger effect sizes than treatment-related factors. Moreover, HRQoL was significantly correlated with CSI, PCS, Patient Health Questionnaire-2, and Generalized Anxiety Disorder-2 scale (all, p < 0.01). On multiple linear regression analysis, CSI accounted for 43% of the variance in HRQoL. Conclusions CS and pain catastrophizing may be more associated with the development and/or maintenance of persistent pain than treatment-related factors.
... This decrease in elasticity and mobility are expressed as increased tenderness or trigger points and adhesions of the myofascial tissues. (7,(9)(10)(11)(12) According to Torres Lacomba et al the prevalence rate of the myofascial pain syndrome is 45% one year after breast cancer surgery. (10) However, these myofascial dysfunctions can contribute to upper limb pain, in the early postoperative phase as well. ...
... (10) However, these myofascial dysfunctions can contribute to upper limb pain, in the early postoperative phase as well. (9,11,13) In physical therapy practice, the aim is to treat this underlying cause of pain with myofascial therapy, i.e. manual release techniques on trigger points and adhesions. (14,15) The added beneficial effects of myofascial therapy for treatment of persistent pain in the late postoperative stage has already been investigated. ...
... The present study found beneficial effects of myofascial therapy on pressure hypersensitivity of upper trapezius muscle and supraspinatus muscle, with the largest effect size for the upper trapezius muscle.The upper trapezius muscle region has already been described as one of the most sensitive areas in breast cancer patients.(17) Pain caused by myofascial dysfunctions can indeed, among other things, manifest as increased pressure hypersensitivity at the upper limb region in breast cancer patients.(11,13) Especially for myofascial trigger points, pressure pain thresholds can be used as evaluation method.(18) ...
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Article
Objective: To investigate the effects of myofascial techniques, in addition to a standard physical therapy programme for upper limb pain shortly after breast cancer surgery. Design: Double-blinded (patient and assessor) randomized controlled trial with two groups. Setting: University Hospitals Leuven, Belgium Patients: A total of 147 patients with unilateral axillary clearance for breast cancer. Intervention: All participants received a standard physical therapy programme starting immediately after surgery for four months. The intervention group received additionally eight sessions of myofascial therapy from two up to four months after surgery. The control group received eight sessions of a placebo intervention, including static hand placements at the upper body region. Main measurements: The primary outcome was prevalence rate of upper limb pain. Additionally, pain intensity (Visual Analogue Scale (VAS, 0-100)), pressure hypersensitivity (pressure pain thresholds (PPTs; kg/cm(2))) and pain quality (McGill Pain Questionnaire) were evaluated. All measurements were performed at 2 (=baseline), 4, 9 and 12 months post-surgery. Results: At 4, 9 and 12 months post-surgery, prevalence rates of pain, pain intensity and pain quality were comparable between the intervention and control group. PPT of the upper trapezius muscle was significantly higher in the intervention group at four months with a difference of -1.2 (-1.9 to -0.4) kg/cm(2), P = 0.012). PPT of the supraspinatus muscle was significantly higher in the intervention group at four months (-0.7 (-1.4 to -0.1) kg/cm(2), P = 0.021) and at nine months (-0.5 (-1.1 to 0.0), P = 0.040). Conclusion: Myofascial therapy has no added beneficial effect as standard physical therapy modality in the postoperative stage.
... 31 This measure has been validated in a variety of pain populations including temporomandibular disorders, 44,45 patellar tendinopathy, 46 low back pain, 47 knee osteoarthritis, 48 myofascial pain 49 and has been used in at least five breast cancer studies. 31,[50][51][52][53] Pressure pain threshold has established reliability (0.60 -0.94 with electric algometers being more reliable than force-gauge models) 31,46,[53][54][55][56][57] and good construct and concurrent validity. 58, 59 Prushansky et al 2004 60 reported a 20% change in pressure is needed to indicate significant change, and results can be compared to published normal values. ...
... 31 This measure has been validated in a variety of pain populations including temporomandibular disorders, 44,45 patellar tendinopathy, 46 low back pain, 47 knee osteoarthritis, 48 myofascial pain 49 and has been used in at least five breast cancer studies. 31,[50][51][52][53] Pressure pain threshold has established reliability (0.60 -0.94 with electric algometers being more reliable than force-gauge models) 31,46,[53][54][55][56][57] and good construct and concurrent validity. 58, 59 Prushansky et al 2004 60 reported a 20% change in pressure is needed to indicate significant change, and results can be compared to published normal values. ...
... 58, 59 Prushansky et al 2004 60 reported a 20% change in pressure is needed to indicate significant change, and results can be compared to published normal values. 31,52,53,55 According to the oncology section EDGE criteria, a measure can be given a 'highly recommend' if it has good psychometric properties and has been used in research with BCS. 19 The acceptable psychometric properties found in multiple populations, and the reference values give the pressure pain threshold a "highly recommended" rating, though the authors acknowledge that the lack of a MDC or MCID in BCS could make it more challenging for clinicians to make decisions based on the results of the measure. ...
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Article
Background: Pain is one of the most commonly reported impairments after breast cancer treatment affecting anywhere from 16-73% of breast cancer survivors Despite the high reported incidence of pain from cancer and its treatments, the ability to evaluate cancer pain continues to be difficult due to the complexity of the disease and the subjective experience of pain. The Oncology Section Breast Cancer EDGE Task Force was created to evaluate the evidence behind clinical outcome measures of pain in women diagnosed with breast cancer. Methods: The authors systematically reviewed the literature for pain outcome measures published in the research involving women diagnosed with breast cancer. The goal was to examine the reported psychometric properties that are reported in the literature in order to determine clinical utility. Results: Visual Analog Scale, Numeric Rating Scale, Pressure Pain Threshold, McGill Pain Questionnaire, McGill Pain Questionnaire - Short Form, Brief Pain Inventory and Brief Pain Inventory - Short Form were highly recommended by the Task Force. The Task Force was unable to recommend two measures for use in the breast cancer population at the present time. Conclusions: A variety of outcome measures were used to measure pain in women diagnosed with breast cancer. When assessing pain in women with breast cancer, researchers and clinicians need to determine whether a unidimensional or multidimensional tool is most appropriate as well as whether the tool has strong psychometric properties.
... The importance and chronicity of such symptoms suggest that the mechanism of pain should be studied in addition to the specific structural pathology [9]. Moreover, previous studies have described widespread pressure pain muscle hypersensitivity as a sign of a central sensitization mechanism in cancer survivors [10,11] and especially in breast cancer patients [10]. Postmastectomy pain is attributed to damage of peripheral nerves during surgery [12]. ...
... The importance and chronicity of such symptoms suggest that the mechanism of pain should be studied in addition to the specific structural pathology [9]. Moreover, previous studies have described widespread pressure pain muscle hypersensitivity as a sign of a central sensitization mechanism in cancer survivors [10,11] and especially in breast cancer patients [10]. Postmastectomy pain is attributed to damage of peripheral nerves during surgery [12]. ...
... The ulnar nerve trunk was identified passing through the olecranon and the medial epicondyle [9]. The tibialis anterior muscle point was established as a distant site in the lower limb [10,30]. ...
Article
Objective This study aims to investigate the presence of bilateral pressure pain hypersensitivity in arm trunk nerves and upper limb mechanosensitivity in breast cancer patients with neck-shoulder pain after medical treatments.Methods Twenty-two breast cancer survivors (mean age 49.05 ± 7.8 years) and matched healthy controls (mean age 50.76 ± 7.6 years) participated in the study. Neck and shoulder pain was evaluated using an 11-point numerical point rating scale. Pressure pain thresholds (PPTs) were bilaterally assessed over the median, radial, and ulnar nerve trunks and tibialis muscle, and the neurodynamics of the upper limb by neural tolerance to movement was evaluated in the median, radial, and ulnar nerves.ResultsThirteen (59.1%) patients reported spontaneous neck pain, and 16 (72.7%) patients showed spontaneous shoulder/axillary pain. Analysis of variance revealed that breast cancer survivors showed significant between-group but not between-side differences over the median nerve trunk (group: P = < 0.001; side: P = 0.146), radial nerve trunk (group: P = < 0.001; side: P = 0.300), ulnar nerve trunk (group: P = < 0.001; side: P = 0.744), and tibialis anterior muscle (group: P = < 0.001; side: P = 0.118). The patients also showed statistically significant differences in range of motion (ROM) between groups and between sides in ULNT1MEDIAN (group: P = < 0.001; side: P = < 0.001) and ULNTULNAR (group: P = 0.009; side: P = 0.002). The analysis did not show statistically significant differences in ROM between groups, but there was a statistical significance between sides for ULNTRADIAL (group: P = 0.081; side: P = 0.046).Conclusions Breast cancer survivors present bilateral and widespread neural hypersensitivity, as they did in muscular tissue in previous studies. Breast cancer survivors demonstrate a reduction in ROM during ULNTs in the affected side.
... [11][12][13][14][15][16] Myofascial pains have also been described in cancer [17] and specifically in PMPS. [18][19][20] Many major nerves supplying the upper limb, shoulder, and chest wall muscles traverse through muscle planes where they are vulnerable to Context: Existing interventions for postmastectomy pain syndrome (PMPS) address the neural component while overlooking a possible myofascial component. Aim: The aim of the study is to investigate the myofascial contribution to PMPS, by examining the effectiveness of myofascial trigger point release by ultrasound-guided dry needling (USGDN). ...
... In agreement with the findings of this study, Fernández-Lao et al. have described MTrPs in the neck and shoulder muscles in patients with PMPS. [18] Ultrasound-guided MTrP injections in the subscapularis and/or pectoralis were found to relieve pain in PMPS. [30] In addition, several reports have shown that Botox, which acts at the motor end plate, [36] can relieve PMPS pain. ...
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Article
Context Existing interventions for postmastectomy pain syndrome (PMPS) address the neural component while overlooking a possible myofascial component. Aim The aim of the study is to investigate the myofascial contribution to PMPS, by examining the effectiveness of myofascial trigger point release by ultrasound-guided dry needling (USGDN). Patients and Methods This retrospective review assessed the efficacy of USGDN in addressing myofascial pain in twenty consecutive patients with treatment-refractory PMPS. Patients in Group 1 (n = 16) received USGDN after neural interventions (NIs) such as neuraxial blocks, intrathecal pump implant, or pulsed radiofrequency, while those in Group 2 (n = 4) received USGDN alone. Outcome measures were changes in Numerical Rating Scale (NRS), PainDETECT (PD), Disabilities of Arm, Shoulder, and Hand (DASH), Patient Health Questionnaire-9 (PHQ-9) scores, and opioid use. Results In Group 1, the mean (standard deviation) NRS and PD scores (9.6 [0.9] and 28.3 [4.3], respectively, at baseline) reduced to 5.2 (1.1) and 16.1 (3.7) at 1-week post-NI. The post-NI DASH reduction was below the cutoff for clinical relevance (80.9 [10.5] at baseline vs. 71.1 [10.5] post-NI). The opioid dose remained unchanged. Following USGDN, NRS, PD, and DASH scores further reduced to 2.3 (0.8), 6.6 (1.2), and 34.6 (14.4), respectively. Patients receiving USGDN alone also showed reduction in NRS, PD, and DASH (7.8 [1.7], 20.0 [8.0], and 61.0 [14.4] at baseline vs. 1.3 [0.5], 6.0 [1.6], and 22.5 [10.4] post-USGDN, respectively). In all patients, opioid use and PHQ-9 scores reduced only post-USGDN. Conclusions USGDN reduced pain, disability, and opioid use, whereas NI reduced only pain. This suggests a myofascial contribution to pain and disability in PMPS.
... First, local pain can be caused by activation of nociceptors of e.g. the musculoskeletal system, the skin and/or connective tissue. [22] Second, neuropathic pain can be present caused by e.g. chemotherapy or the sensory intercostal brachial nerve which can be damaged during surgery. ...
... [23][24][25] Third, more widespread, generalized pain might be present and can be explained by the presence of sensitization of the central nervous system. [22,26] At last, a combination of different pain mechanisms may be present. [27] In the present study patients with pain at the arm and upper body and myofascial dysfunctions were included. ...
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Article
Objective: To investigate the effect of myofascial therapy in addition to a standard physical therapy program for treatment of persistent arm pain after finishing breast cancer treatment. Design: Double-blinded (patient and assessor) randomized controlled trial. Setting: University Hospitals Leuven, Belgium. Patients: A total of 50 patients with persistent arm pain and myofascial dysfunctions after breast cancer treatment. Intervention: Over three months, all patients received a standard physical therapy program. The intervention group received in addition 12 sessions of myofascial therapy, and the control group received 12 sessions of placebo therapy. Main measurements: Main outcome parameters were pain intensity (primary outcome) (maximum visual analogue scale (VAS) (0-100)), prevalence rate of arm pain, pressure hypersensitivity (pressure pain thresholds (kg/cm(2)) and pain quality (McGill Pain Questionnaire). Measures were taken before and after the intervention and at long term (6 and 12 months follow-up). Results: Patients in the intervention group had a significantly greater decrease in pain intensity compared to the control group (VAS -44/100 vs. -24/100, P = 0.046) with a mean difference in change after three months between groups of 20/100 (95% confidence interval, 0.4 to 39.7). After the intervention, 44% versus 64% of patients still experienced pain in the intervention and control group, respectively ( P = 0.246). No significant differences were found for the other outcomes. Conclusion: Myofascial therapy is an effective physical therapy modality to decrease pain intensity at the arm in breast cancer survivors at three months, but no other benefits at that time were found. There were no long-term effects at 12 months either.
... Further, exposure to neurotoxic chemotherapy may increase the risk of peripheral sensory disturbances [16]. Recent studies have reported pressure pain hypersensitivity, i.e., increased sensitivity to pain in the upper limb as a sign of a central sensitization mechanism in women after standard treatment of breast cancer, i.e., a combination of axillary dissection, radiotherapy, and chemotherapy [17,18]. ...
... A total of 28 points on the frontal and dorsal part of the neck-shoulder region (15 points over the upper trapezius muscle, six points over the anterior portion of the deltoid muscle, six points over the pectoralis major muscle, and one point over the tibialis anterior muscle as a distant reference point) [30] were measured bilaterally on each participant with a 30-second resting period between assessments. The distribution of points was chosen taking into account the previous maps described in the neck-shoulder regions [23,25] and the previous description of pain patterns in the breast cancer survivors [17]. The assessments were performed twice over two rounds in random order, and a third time if the point assessed had a coefficient of variance over 0.2 [21]. ...
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Article
Objective: The aim of the present study was to report pressure pain sensitivity topographical maps of the frontal and dorsal parts of the shoulder region, and locate the pressure pain sensitive areas in breast cancer survivors compared with matched healthy control subjects. Methods: Twenty-two breast cancer survivors (BCS) and 22 matched control subjects participated. A numeric pain rating scale of the neck-shoulder area and pressure pain thresholds (PPTs) was assessed bilaterally over 28 points in the frontal and dorsal neck-shoulder area. Topographical pain sensitivity maps of the upper trapezius, pectoral, and anterior deltoid areas were computed. Results: A three-way analysis of variance was carried out to evaluate the differences in PPTs. The BCS reported spontaneous neck pain (mean ± SD 3.6 ± 2.8), pain in the affected shoulder (4.3 ± 2.7), and pain in the non-affected shoulder (0.9 ± 1.8). Additionally, the BCS exhibited bilaterally lower PPTs in all the measurement points as compared with the control subjects (P < 0.05). The PPTs were lower at the superior part of the trapezius muscle (P < 0.001), the musculotendinous insertion, the anterior part of the deltoid muscle (P < 0.001), and the tendon of the pectoral muscle (P < 0.001) as compared with the control subjects. Conclusions: The results suggest the sensitization processes in the BCS and give preliminary evidence to most sensitive areas in the superior part of the upper trapezius and musculotendinous insertion of the pectoral muscle.
... 2 Numerous studies have shown that MTrPs are prevalent in patients with chronic musculoskeletal pain. [3][4][5][6][7][8] In the sedentary lifestyle in today's societies with too much time in static postures, phasic muscles become progressively inhibited and lax, while postural muscles gradually become tighter. A muscle imbalance between dynamic and postural muscles may lead to MTrPs in the cervical region. ...
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Article
Purpose: To determine the difference in maintenance of improvement of pain and disability for dry needling (DN) under needle electromyography (EMG) guidance technique in myofascial neck and shoulder pain patients, compared with DN alone. Patients and methods: In this randomized single-blind clinical trial, 30 participants with myofascial pain in the neck and shoulder were randomly allocated to two groups: myofascial trigger points (MTrPs) DN with EMG guided (DN-EMG) group and MTrPs DN without EMG (DN) group. Needling treatment lasted for 2 weeks, twice a week. The primary outcome was pain intensity as assessed by visual analogue scale (VAS) and neck disability index (NDI). A number of mappings referred to pain and spontaneous muscle activity (SEA) were considered secondary outcomes. VAS and NDI were measured before treatment, after 2 weeks of intervention and at 4-, 6- and 12-week follow-up periods after the intervention. Secondary outcomes were assessed before each treatment (T1-T4). Data were analysed using mixed-model analyses of variance (ANOVA) with time as a within-subject variable and groups as between-subject variables followed by Bonferroni's post-hoc test. Results: Mixed-model ANOVA revealed significant time-by-group interaction effects (F = 3.49, P = 0.01) for VAS. Post-hoc analysis showed a significant decrease in VAS and NDI after 2 weeks of intervention and at all follow-up periods compared with baseline in both groups (p < 0.01). The DN-EMG group exhibited higher improvements in VAS at 6- and 12-week follow-up period than the DN group (p < 0.05). In the SEA of MTrPs, we found positive sharp waves, fibrillation and fascicular potentials. DN-EMG group exhibited lower amplitudes at T2-T4 and frequencies at T2 and T3. Conclusion: DN under needle EMG guidance technique exhibited greater improvements in maintenance of improvement of pain and lower SEA value than the DN group due to sufficient MTrPs inactivation.
... 6,31 TrPs were bilaterally explored in the face-to-face assessment by a blinded assessor in muscles described to refer pain to the shoulder in response to compression, performing the assessment following the criteria described by Simons et al. 32 This exploration has been also realized in other thoracic cancer entities. 33,34 The exploration included the follow muscles: trapezius, pectoralis major and minor, deltoids, supraspinatus, elevator scapulae, subscapularis, and latissimus dorsi. The order of points was randomized between subjects with a 2 min rest period between muscles, as previously used, 35 in order to avoid the referred pain interfering with the patient's response. ...
Article
Introduction Upper limb disability can limit the quality of life of lung cancer survivors. The COVID-19 era has required a finding of alternatives to attend the monitoring of presented disturbances with the minor risk of spread. Tele-assessment offers new possibilities for clinical assessment demonstrating good reliability compared to traditional face-to-face assessment in a variety of patients. No previous study has applied this type of assessment in lung cancer survivors. For this reason, the aim of this study was to evaluate the level of agreement between upper limb disability assessment using tele-assessment and the face-to-face method in lung cancer survivors. Methods A reliability study was conducted with 20 lung cancer survivors recruited from the Oncological Radiotherapy Service of the “Hospital PTS” (Granada). Patients attended a session for clinical face-to-face and real-time online tele-assessment. The main outcome measurements of the study included upper limb function (shirt task) and musculoskeletal disturbances (active range of movement and trigger points), and these outcomes were recorded by two independent researchers. Results The outcome measures showed good agreement between both assessments. The active range of movement presented heterogeneous results, being excellent reliability ( ρ > 0.75) in extension, internal rotation, homolateral adduction, and contralateral abduction, good (0.4 < ρ < 0.75) for flexion, homolateral abduction, contralateral adduction and contralateral external rotation, and poor ( ρ < 0.4) for homolateral external rotation. The measure evaluating upper limb function and trigger points show the highest interrater reliability with confidence interval lower limits ≥0.99. Discussion The tele-assessment of upper limb function and musculoskeletal disorders of lung cancer survivors present a good interrater reliability compared to face-to-face assessment. It could be useful for monitoring the disability presented by cancer survivors whose access is difficult by the residential situation, physical limitations or the risk of COVID-19 spread.
... Within this context, quantitative sensory testing (QST) is another plausible tool to be used in the presence of myofascial trigger points, since it involves a set of methods to assess somatosensory function, including measuring the presence of hyperalgesia and allodynia 7 . It is noteworthy that the myofascial trigger points actively participate in the peripheral and central sensitization processes, as highlighted by important studies [8][9][10] . ...
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OBJECTIVE: The objective of this study was to measure the intra- and inter-rater reliability of the quantitative sensory testing for measuring the thermal pain threshold on myofascial trigger points in the upper trapezius muscle of individuals with chronic neck pain. METHODS: Thirty female participants were included, aged between 18 and 45 years and with bilateral myofascial trigger points, active and centrally located in the upper trapezius muscle. Two measurements with quantitative sensory testing were performed by each examiner at an interval of 1 week between them. RESULTS: We observed substantial reliability for the intra-rater analysis (intraclass correlation coefficient ranging between 0.876 and 0.896) and excellent reliability for the inter-rater analysis (intraclass correlation coefficient ranging between 0.917 and 0.954). CONCLUSION: The measurement of the thermal pain threshold on myofascial trigger points in individuals with chronic neck pain has acceptable reliability values, supporting the use of the quantitative sensory testing in the research setting and the clinical environment.
... Additionally, a "PPT index" was calculated as previously suggested [29]. Briefly, PPTs of each patient were divided by the mean score for the same anatomical point in the control group, and finally multiplied by 100. ...
Article
Objective: To explore hypersensitivity to pain and musculoskeletal impairments in the lumbopelvic area in women with and without endometriosis. Methods: This cross-sectional study included 66 women (41 women with endometriosis and 25 healthy women). Pain and related catastrophizing thoughts were assessed through a numeric rating scale, pressure pain thresholds (PPTs), the slump test, and the Pain Catastrophizing Scale. Lumbopelvic muscles were evaluated through ultrasound imaging, flexor/extensor resistance tests, and the lumbopelvic stability test. Results: Women with endometriosis showed increased self-reported intensity of current pelvic pain (CuPP), reduced local PPTs (42.8-64.7% in the affected area, P-value <.001) and higher prevalence of lumbar nerve root impingement/irritation pain and catastrophizing thoughts (P-value ≤.002). Moreover, affected women showed decreased thickness of transversus abdominis, reduced resistance of flexor and extensor trunk muscles and lower lumbopelvic stability (P-values <.030). Endometriosis stage and severity of CuPP were related to worse results in these parameters. Conclusions: The presence of pain sensitization signs and lumbopelvic impairments, more pronounced in patients with stage IV endometriosis and moderate/severe CuPP, warrants the development of rehabilitation interventions targeting pain and lumbopelvic impairments in women with endometriosis.
... Myofascial trigger points were more common after surgery, but no significant differences were observed between patients undergoing lumpectomy and those undergoing mastectomy. Two other prospective studies reported a decreased pressure pain threshold and increased frequency of active trigger points in the cervical and shoulder muscles of breast cancer patients with neck and shoulder pain as compared to a matched group of healthy controls with no pain [38,39]. As noted above, these results should be viewed in light of the selection bias of patients with pain in the cancer group as opposed to pain-free patients in the control group. ...
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Article
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.
... Fernandez-Lao et al. (Fernandez-Lao et al., 2010) examined the prevalence of MTrPs in the neck and shoulder muscles of patients suffering from post-mastectomy pain. MTrPs were considered active when digital compression evoked local and referred pain that reproduced pain symptoms that the patient recognized as familiar. ...
Article
Background: Pain is a common complaint of cancer patients, experienced by 38%–85% of patients. Some studies have shown a high incidence of myofascial pain syndrome (MPS) in cancer patients. Aims: 1) To estimate the prevalence of MPS in cancer patients; 2) to examine the efficacy of current treatment options for MPS in cancer patients. Methods: Narrative review. PubMed, CINAHL, PEDro, and Google Scholar databases were searched from inception until November 2017, for the keywords: cancer; cancer pain; breast cancer; mastectomy; lumpectomy; myofascial pain; trigger points. Trials of any methodological quality were included. All published material with an emphasis on randomized control trials was analyzed. Results: MPS is prevalent in cancer patients who suffer from pain, with a prevalence of between 11.9% and 44.8% in those diagnosed either with neck or head or breast cancer. Clinical studies showed conflicting results. Four interventional studies found that specific treatment for MPS may reduce the prevalence of active myofascial trigger points and therefore decrease pain level, sensitivity, and improve range of motion (in shoulder) in cancer patients. Two recent randomized control trials showed that pressure release of trigger points provides no additional beneficial effects to a standard physical therapy program for upper limb pain and function after breast cancer surgery. Conclusions: We recommend including the evaluation of myofascial pain in routine clinical examination of cancer patients suffering from pain. Future studies are needed to investigate the long- and short-term effect of MPS treatments in cancer patients.
... It has been suggested in previous studies that, independent of the type of surgery, both peripheral and CS mechanisms are present in BCS. 24,25 Due to the nature of the disease and the multimodal treatment, breast cancer patients are often exposed to a mixture of nociceptive, neuropathic, and/or CS pain, also called mixed pain. 15 Still, prevalence data of the 3 main types of pain within the BCS population are currently lacking. ...
Article
Introduction The differentiation between acute and chronic pain can be insufficient for an appropriate pain management. The aim of this study was to evaluate the prevalence of the predominant pain type (nociceptive, neuropathic or central sensitization pain) in breast cancer survivors (BCS) with chronic pain. The secondary aims were to examine 1) differences in health‐related quality of life(HRQoL) between the different pain groups; 2) the associations between patient‐, disease‐ and treatment‐related factors and the different pain types. Methods To determine the prevalence of the predominant type of pain, a recently proposed classification system was used. BCS were asked to complete the Visual Analog Scale for pain (VAS), Douleur Neuropathique 4 Questionnaire (DN4), Margolis Pain Diagram, Central Sensitization Inventory (CSI) and Short form 36 (SF‐36). Results 91 BCS participated, whereof 25.3% presented neuropathic pain, 18.7% nociceptive pain and 15.4% central sensitization (CS) pain. Mixed pain was found in 40.6%. A significant intergroup difference in HRQoL was found for SF‐36 “general health” (p=0.04). The odds for the presence of CS rather than nociceptive pain, are 26 times higher in patients exposed to hormone therapy in comparison to the non‐exposed (OR:25.95,95%CI 1.33–504.37, p=0.03). Conclusion Neuropathic pain is most frequent in BCS. Strong associations were found between CS and hormone therapy. This article is protected by copyright. All rights reserved.
... Besides this painful sensitization it is greater if the patient is practiced mastectomy instead of a lumpectomy [66]. In fact, in previous studies, the presence of central nervous system hypersensitivity has already been reported in BCS [67]. The results of this pilot study indicate that the subject's pressure sensitivity does not change significantly at any level or group after taping applications. ...
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Article
Background: Aromatase inhibitors reduce breast cancer recurrence rates in postmenopausal women by about 30% compared with tamoxifen while treatments differ. Unfortunately, nearly half of women taking AIs report AI-associated arthralgia (AIA), leading to therapy abandon in on third of patients, which could lead to cancer recurrence. The purpose of the current study was to evaluate the effectiveness of Neuromuscular Taping (NMT) in the treatment of AIA in women who have been treated of BC. Methods: This study included 40 BC survivors receiving endocrine therapy (either AIs or TMX) from Hospital Universitario Virgen de la Victoria (Málaga, Spain) suffered from AIA. Patients were randomized to one of the two groups that made this pilot study: A. Placebo intervention B. Real NMT. Clinical data were collected from medical history, grip strength, algometry measured, questionnaires and VAS scale. There have been three interventions prior to the completion of the study, 5 weeks later. The primary objective of this pilot study was to achieve an improvement of pain by 20% decrease of VAS. Results: Significant differences in measures of VAS (p = 0.009), global health status/QoL (p = 0.005), fatigue (p = 0.01) and pain (p = 0.04) were observed post intervention with NMT. Conclusions: An intervention by NMT to MSCM under treatment with AIs improves their subjective sensation of pain. In addition, this taping had an impact on variables related to the quality of life. This pilot study may be the basis for others to support the use of NMT for the treatment of AIAs, thereby improving their well-being and reducing the dropout rate. Trial registration: ClinicalTrials.gov Identifier: NCT02406794 . Registered on 2 April 2015 Retrospectively registered.
... [3] Both myofascial trigger points and adhesions and/or restrictions between the myofascial tissues layers can contribute to a patient's pain complaint. [3][4][5][6][7] For myofascial trigger points, several criteria to determine their presence have already been postulated. [3,8,9] For the evaluation of myofascial adhesions, the Myofascial Adhesions in Patients after Breast Cancer (MAP-BC) evaluation tool has been developed by De Groef et al. [10] This tool evaluates the degree of myofascial adhesions at 7 anatomical locations (axillary and breast region scars, pectoral muscles region, axilla, frontal chest wall, lateral chest wall and inframammary fold) in breast cancer patients. ...
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Article
Purpose To investigate the concurrent, face and content validity of an evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool). Methods 1) Concurrent validity of the MAP-BC evaluation tool was investigated by exploring correlations (Spearman’s rank Correlation Coefficient) between the subjective scores (0 –no adhesions to 3 –very strong adhesions) of the skin level using the MAP-BC evaluation tool and objective elasticity parameters (maximal skin extension and gross elasticity) generated by the Cutometer Dual MPA 580. Nine different examination points on and around the mastectomy scar were evaluated. 2) Face and content validity were explored by questioning therapists experienced with myofascial therapy in breast cancer patients about the comprehensibility and comprehensiveness of the MAP-BC evaluation tool. Results 1) Only three meaningful correlations were found on the mastectomy scar. For the most lateral examination point on the mastectomy scar a moderate negative correlation (-0.44, p = 0.01) with the maximal skin extension and a moderate positive correlation with the resistance versus ability of returning or ‘gross elasticity’ (0.42, p = 0.02) were found. For the middle point on the mastectomy scar an almost moderate positive correlation with gross elasticity was found as well (0.38, p = 0.04) 2) Content and face validity have been found to be good. Eighty-nine percent of the respondent found the instructions understandable and 98% found the scoring system obvious. Thirty-seven percent of the therapists suggested to add the possibility to evaluate additional anatomical locations in case of reconstructive and/or bilateral surgery. Conclusions The MAP-BC evaluation tool for myofascial adhesions in breast cancer patients has good face and content validity. Evidence for good concurrent validity of the skin level was found only on the mastectomy scar itself.
... Forty-seven (78.5%) experts agreed that referred pain elicited by a TrP could include different sensory sensations and not just pain. There is scientific evidence supporting that TrPs elicit pain referral that mimicks a great variety of sensory symptoms, that is, dull/burning pain in tension-type headache [18], throbbing pain reproducing migraine attacks [19], symptoms compatible to peripheral neuropathies such as carpal tunnel syndrome [20], or sensory symptoms associated with postmastectomy pain [21]. Most experts also replied that they do not expect a predefined pattern of referred pain for a specific muscle as described by Simons et al. [1]. ...
Article
Objective: There is no consensus on the essential diagnostic criteria for diagnosing a trigger point (TrP). In fact, a variety of diagnostic criteria are currently being used. Our aim was to conduct a Delphi panel to achieve an international consensus on the cluster of criteria needed for the TrP diagnosis to reach a consensus on the definition of active and latent TrPs and to clarify different clinical considerations about TrPs. Methods: Following international guidelines, an international three-round Delphi survey was conducted. Questions were created based on a systematic literature search of the diagnostic criteria for TrPs. Results: Sixty experts from 12 countries completed all rounds of the survey. A cluster of three diagnostic criteria was proposed as essential for the TrP diagnosis: a taut band, a hypersensitive spot, and referred pain. Eighty percent of the experts agreed that the referred pain elicited by a TrP can include different sensory sensations and not just pain, that is, pain spreading to a distant area, deep pain, dull ache, tingling, or burning pain. Eighty-four percent of the international experts consistently answered that the main clinical differences between active and latent TrPs are the reproduction of any of the symptoms experienced by a patient and the recognition of pain. No specific location of the pain referral area and TrP location should be expected. Conclusions: This Delphi panel has produced an expert-based standardized definition of a TrP with a discussion of the clinical components, including the definition of referred pain and the difference between active and latent TrPs, thereby providing a foundation for future research in MPS.
... The latter are impairments of gliding of the myofascial tissues relative to each other. [5][6][7][8][9] Muscle manipulation during surgery, scar tissue formation, soft tissue adhesions and adaptive postures following surgery or fibrosis from radiotherapy can cause myofascial adhesions. [3,4,7,9] Currently, several criteria to determine the presence of myofascial trigger points are established. ...
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Article
Purpose To develop a tool to evaluate myofascial adhesions objectively in patients with breast cancer and to investigate its interrater reliability. Methods 1) Development of the evaluation tool. Literature was searched, experts in the field of myofascial therapy were consulted and pilot testing was performed. 2) Thirty patients (63% had a mastectomy, 37% breast-conserving surgery and 97% radiotherapy) with myofascial adhesions were evaluated using the developed tool by 2 independent raters. The Weighted Kappa (WK) and the intra-class correlation coefficient (ICC) were calculated. Results 1) The evaluation tool for Myofascial Adhesions in Patients with Breast Cancer (MAP-BC evaluation tool) consisted of the assessment of myofascial adhesions at 7 locations: axillary and breast region scars, musculi pectorales region, axilla, frontal chest wall, lateral chest wall and the inframammary fold. At each location the degree of the myofascial adhesion was scored at three levels (skin, superficial and deep) on a 4-points scale (between no adhesions and very stiff adhesions). Additionally, a total score (0–9) was calculated, i.e. the sum of the different levels of each location. 2) Interrater agreement of the different levels separately was moderate for the axillary and mastectomy scar (WK 0.62–0.73) and good for the scar on the breast (WK >0.75). Moderate agreement was reached for almost all levels of the non-scar locations. Interrater reliability of the total scores was the highest for the scars (ICC 0.82–0.99). At non-scar locations good interrater reliability was reached, except for the inframammary fold (ICC = 0.71). Conclusions The total scores of all locations of the MAP-BC evaluation tool had good to excellent interrater reliability, except for the inframammary fold which only reached moderate reliability.
... La structure devient hypersensible et a tendance à provoquer des douleurs plus tôt et plus intenses lors de sa mise en contrainte. C'est, par exemple, ce que l'on expérimente lors des courbatures, ou lors de tests de mise en tension neurale en présence d'une neuropathie comme la sciatalgie[2,[85][86][87]. La situation de sensibilisation centrale est plus complexe, mais est identifiée dans un grand nombre de pathologies[27]. ...
Article
Résumé Introduction La douleur est une sensation désagréable perçue dans une région du corps. Elle est la principale cause de consultation en physiothérapie et a un fort impact individuel social lorsqu’elle devient chronique. Des études ont montré que savoir expliquer la neurophysiologie de la douleur aux patients a un effet bénéfique sur leur récupération. Nous résumons les données neurophysiologiques permettant d’appréhender le phénomène de la nociception et de la douleur. Méthode Nous avons entrepris une revue narrative de la littérature sur le domaine de la douleur, la sensibilisation périphérique et centrale, sur les modifications des systèmes de perceptions et modulation de la douleur dans le cas de douleurs chroniques. Résultats La douleur est une perception consciente modulable. Suite au processus d’inflammation induit par une atteinte tissulaire les nocicepteurs périphériques deviennent sensibilisés (abaissement du seuil de perception, activité spontanée accrue, production de molécules pro-inflammatoires). Ce phénomène rend compte de l’état d’hyperalgésie primaire. Suite à une activité intense et/ou prolongée des afférences nociceptives, les neurones de la corne dorsale de la moelle épinière peuvent être sensibilisés (abaissement du seuil de perception, activité spontanée accrue, augmentation du champ récepteur). Ce phénomène explique pour partie les phénomènes d’hyperalgésies secondaire et tertiaire, ainsi que l’allodynie. D’autres modifications supra-segmentaires ont été rapportées dans diverses pathologies douloureuses chroniques (perte de substance grise, altération des connexions intracérébrales, modifications de l’activité électrique cérébrale). Ces modifications, spécifique aux présentations cliniques, sont suspectées de participer au maintien du phénomène de douleur chronique. Discussion Cet article résume une partie de la littérature scientifique sur le phénomène de la douleur et apporte des données utiles à l’éducation des patients afin d’améliorer leur prise en charge. Niveau de preuve Non applicable.
... Second, the awareness on the presence of altered pain processing and sensitisation of the central nervous system in breast cancer patients has increased but its contribution to upper limb dysfunctions has not yet been investigated. [14][15][16] Further, the awareness on the influence of psychosocial factors to recovery of upper limb function has increased resulting in a more biopsychosocial approach. 14,17 However, it has not been investigated either if certain pain-related psychosocial factors such as pain catastrophizing and vigilance and awareness to pain are associated with upper limb function in breast cancer patients. ...
Article
Purpose: The aim of this study was to explore the treatment, patient, and impairment-related risk factors associated with upper limb dysfunctions in breast cancer survivors. Methods: A cross-sectional study was performed in 274 women treated for breast cancer. The following risk factors were analysed by bivariable and multivariable analysis: 1) treatment-related variables (type of surgery, levels of lymph node dissected, radiotherapy, chemotherapy, hormone therapy and trastuzumab); 2) patient's related variables (age and Body Mass Index); 3) and finally impairment-related variables such as pain (intensity, quality and pressure hypersensitivity, signs of central sensitisation, the degree of pain catastrophizing and vigilance and awareness to pain), active ROM and upper limb strength were investigated. The dependent variable was upper limb function measured with the Disability of Arm, Shoulder and Hand (DASH) questionnaire. Additionally, a stepwise regression was performed. Results: An impaired upper limb function was noted in 170 (62%) of patients. Mean time after surgery was 1.5 (1.6) years. From multivariable analysis, it appears that in particular certain pain characteristics such as pain intensity, pain quality, signs of central sensitisation and pain catastrophizing are contributing to upper limb dysfunctions after breast cancer treatment at long term. Additionally, higher age, shoulder ROM and handgrip strength are possible contributing factors. The stepwise regression analysis revealed that central sensitisation mechanisms alone can explain about 40% of the variance in upper limb function. Conclusions: At long term, especially pain and central sensitisation mechanisms contribute to upper limb function in breast cancer survivors.
... [31][32][33] These studies revealed widespread pressure pain hypersensitivity in people treated for breast or colon cancer. [31][32][33] However, some studies found only local hypersensitivity [33,34] and studies investigating other features of central sensitization pain (peripherally driven central excitability and dysfunctional endogenous analgesia) are inconclusive. [35][36][37] Together these findings suggest that pain following cancer treatment is not always dominated by central sensitization, but instead may be present in a subgroup. ...
Article
Aim: Pain is the second most frequent persistent symptom following cancer treatment. This article aims at explaining how the implementation of contemporary pain neuroscience can benefit rehabilitation for adults following cancer treatment within an evidence-based perspective. Materials and methods: Narrative review. Results: First, pain education is an effective but underused strategy for treating cancer related pain. Second, our neuro-immunological understanding of how stress can influence pain highlights the importance of integrating stress management into the rehabilitation approach for patients having cancer-related pain. The latter is supported by studies that have examined the effectiveness of various stress management programmes in this population. Third, poor sleep is common and linked to pain in patients following cancer treatment. Sleep deprivation results in a low-grade inflammatory response and consequent increased sensitivity to pain. Cognitive behavioural therapy for sleep difficulties, stress management and exercise therapy improves sleep in patients following cancer treatment. Finally, exercise therapy is effective for decreasing pain in patients following cancer treatment, and may even decrease pain-related side effects of hormone treatments commonly used in cancer survivors. Conclusions: Neuro-immunology has increased our understanding of pain and can benefit conservative pain treatment for adults following cancer treatment. Implications for Rehabilitation Pain education is effective for improving cancer pain; implementation of contemporary pain neuroscience into the educational programme seems warranted. Various types of stress management are effective for treating patients following cancer treatment. Poor sleep is common in patients following cancer treatment, and rehabilitation specialists can address this by providing exercise therapy, sleep hygiene, and/or cognitive behavioural therapy. Exercise therapy is effective for decreasing pain in patients following cancer treatment, including the treatment of pain as a common side effect of hormone treatments for breast cancer survivors.
... [36] Besides, Hodges believes that the pain may change the mechanical behavior and movement patterns to protect subjects from more pain and potential damages. [37] Considering MTPs as a source of persistent activation of muscle nociceptors [38] combined with Hodge's claims, DN may alter movement and activation patterns in paraspinals, and other muscles by deactivating MTPs. [39] Therefore, the pathological movement disorders would gradually fade and be replaced by new patterns. ...
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Background Disk herniation is the most common cause of radiating low back pain (LBP) in subjects under 60 years of age. The present study aims to compare the effect of dry needling (DN) and a standard conservative approach on the pain and function in subjects with discogenic radiating LBP. Materials and Methods Fifty-eight subjects with discogenic radicular LBP were screened and randomized into control (Standard physical therapy, n = 29) and experimental group (Standard physical therapy and DN, n = 29). Radiating pain intensity and disability were measured using visual analog scale (VAS) and Oswestry Disability indices at baseline, at the end of treatment and 2 months after the last intervention session. The changes in pain intensity and disability were studied using a 3 × 2 repeated measures analysis of variance considering time as the within-subject factor and group as the between-subject. Results Pain intensity and disability scores decreased significantly in both experimental and control groups (experimental group: VAS = 37.24, Oswestry Disability Index [ODI] =28.48, control group: VAS = 45.5, ODI = 32.96), following the intervention. The change continued during the follow-up period (P < 0.001 for all comparisons). Pain and disability improvement, however, were more significant in experimental group, both in post intervention (experimental group: VAS = 25.17, ODI = 22.17, control group: VAS = 42.4, ODI = 30.27) (P = 0.05 and P = 0.03, respectively) and follow-up measures (P = 0.006 and P = 0.002, respectively). Conclusion Both intervention strategies seem to significantly improve pain and disability immediately following intervention, where the improvement continued during 2 months after the last active intervention. Therefore, supplementary DN application may enhance the effect of the standard intervention considerably.
... 3 Nowadays, the growing evidences suggest that the decline of pain threshold induced by peripheral and central sensitization is involved in the generation of referred pain. [5][6][7] To date, however, no study has examined the changes of pain threshold in shoulder muscles after laparoscopies. ...
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Article
Objectives Postlaparoscopic shoulder pain (PLSP) remains a common problem after laparoscopies. The aim of this study was to investigate the correlation between pressure pain threshold (PPT) of different muscles and PLSP after gynecologic laparoscopy, and to explore the effect of parecoxib, a cyclooxygenase-2 inhibitor, on the changes of PPT. Materials and methods The patients were randomly allocated into two groups; group P and group C. In group P, parecoxib 40 mg was intravenously infused at 30 minutes before surgery and 8 and 20 hours after surgery. In group C, normal saline was infused at the corresponding time point. PPT assessment was performed 1 day before surgery and at postoperative 24 hours by using a pressure algometer at bilateral shoulder muscles (levator scapulae and supraspinatus) and forearm (flexor carpi ulnaris). Meanwhile, bilateral shoulder pain was evaluated through visual analog scale score at 24 hours after surgery. Results Preoperative PPT level of the shoulder, but not of the forearm, was significantly and negatively correlated with the intensity of ipsilateral PLSP. In group C, PPT levels of shoulder muscles, but not of forearm muscles, decreased after laparoscopy at postoperative 24 hours. The use of parecoxib significantly improved the decline of PPT levels of bilateral shoulder muscles (all P<0.01). Meanwhile, parecoxib reduced the incidence of PLSP (group P: 45% vs group C: 83.3%; odds ratio: 0.164; 95% confidence interval: 0.07–0.382; P<0.001) and the intensity of bilateral shoulder pain (both P<0.01). Conclusion Preoperative PPT levels of shoulder muscles are closely associated with the severity of shoulder pain after gynecologic laparoscopy. PPT levels of shoulder muscles, but not of forearm muscles, significantly decreased after surgery. Parecoxib improved the decrease of PPT and relieved PLSP.
... PPTs were assessed bilaterally over the following anatomical landmarks and in this order: 1) suboccipital muscle, 2) upper fibers trapezius muscle (midway between C7 and the acromion), 3) lateral epicondyle, and 4) anterior tibial muscle (upper third of the muscle belly). All these anatomical landmarks were used previously by other researchers (18,(30)(31)(32)(33)(56)(57)(58). Measurements were first performed on the right side and then on the left side. ...
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Background: Neck pain has an elevated prevalence worldwide. Most people with neck pain are diagnosed as nonspecific neck pain patients. Poor recovery in neck disorders, as well as high levels of pain and disability, are associated with widespread sensory hypersensitivity. Nevertheless, there is controversy regarding the presence of widespread hyperalgesia in chronic nonspecific neck pain (CNSNP); this lack of agreement could be due to the presence of different pathophysiological mechanisms in CNSNP. Objectives: To determinate differences in pressure pain thresholds (PPTs) over extracervical and cervical regions, and differences in cervical range of motion (ROM) between patients with CNSNP with and without neuropathic features (NF and No-NF, respectively). In addition, this study expected to observe correlations in these 2 types of CNSNP of psychosocial factors with PPTs and with cervical ROM separately. Study design: Descriptive, cross-sectional study. Setting: A hospital physiotherapy outpatient department. Methods: This research involved 53 patients with CNSNP that had obtained a Self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS) score = 12 (pain with NF, NF group); 54 that had obtained a S-LANSS score < 12 (pain with No-NF, No-NF group), and 53 healthy controls (control group, CG). Measures included: PPTs (suboccipital muscle, upper fibers trapezius muscle, lateral epicondyle, and anterior tibial muscle), cervical ROM (flexion, extension, rotation, and latero-flexion), pain intensity (Visual Analog Scale [VAS]), neck disability index (NDI), kinesiophobia (Tampa Scale of Kinesiophobia-11 [TSK-11]), and Pain Catastrophizing Scale (PCS). Results: A statistically significant effect was observed for the group factor in all assessed measures (P < 0.01). Both CNSNP groups showed statistically significant differences compared to the CG for PPTs in the cervical region (suboccipital and upper fibers trapezius muscles), but only the NF group demonstrated statistically significant differences for PPTs in the lateral epincondyle and anterior tibial muscle when compared to the CG or No-NF group. The largest statistically significant correlation found in the NF group was between PPT in the anterior tibial muscle and TSK-11 (r = -0.372; P < 0.01), while in the No-NF group it was between PPT in the suboccipital muscle and NDI (r = -0.288; P < 0.05). Statistically significant differences were found between the 2 CNSNP groups and CG in all cervical ROMs, but not between both CNSNP groups. The largest statistically significant correlation observed in the NF group was between cervical total rotation and TSK-11 (r = -0.473; P < 0.01), while in the No-NF group it was between cervical total latero-flexion and PCS (r = -0.532; P < 0.01). Limitations: Although the S-LANSS scale has been validated as a screening tool for pain with NF, currently there is no "gold standard," so these findings should be interpreted with caution. Conclusions: Widespread pressure pain hyperalgesia was detected in patients with CNSNP with NF, but not in patients with CNSNP with No-NF. Patients with CNSNP presented bilateral pressure pain hyperalgesia over the cervical region and a decreased cervical ROM compared to healthy controls. However, no differences were found between the 2 CNSNP groups. These findings suggest differences in the mechanism of pain processing between patients with CNSNP with NF and No-NF.
... In addition, other muscles, such as the levator scapulae, biceps brachii, deltoid, pectoralis minor, pectoralis major, scalene, latissimus dorsi, teres major and minor muscles may also be involved in shoulder pain. In fact, two studies demonstrated that TrPs in the latissimus dorsi and pectoralis major muscles reproduced axillary arm pain in women with breast cancer who had undergone mastectomies ( Fernández-Lao et al. 2010, Torres-Lacomba et al. 2010 Studies investigating the effect of TrP therapy in patients with shoulder pain are sparse. Recently, two randomized controlled trials showed promising results of manual TrP therapy in patients with shoulder pain ( Hains et al. 2010, Bron et al. 2011a ). ...
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This exciting new publication is the first authoritative resource on the market with an exclusive focus on Trigger Point ((TrP) dry needling. It provides a detailed and up-to-date scientific perspective against which TrP dry needling can be best understood. The first section of the book covers important topics such as the current understanding and neurophysiology of the TrP phenomena, safety and hygiene, the effect of needling on fascia and connective tissue, and an account on professional issues surrounding TrP dry needling. The second section includes a detailed and well-illustrated review of deep dry needling techniques of the most common muscles throughout the body. The third section of the book describes several other needling approaches, such as superficial dry needling, dry needling from a Western Acupuncture perspective, intramuscular stimulation, and Fu’s subcutaneous needling. Trigger Point Dry Needling brings together authors who are internationally recognized specialists in the field of myofascial pain and dry needling. First book of its kind to include different needling approaches (in the context of evidence) for the management of neuromuscular pain conditionsHighlights both current scientific evidence and clinicians’ expertise and experience Multi-contributed by a team of top international experts Over 200 illustrations supporting the detailed description of needling techniques.
... In this novel study, we used a case-controlled design, which is frequently used in studies with oncology patient (Fernández-Lao et al., 2010;Sánchez-Jiménez et al., 2014), to analyze vagal-nerve activity while considering different confounder variables. However, we should acknowledge some limitations. ...
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The same aggressive treatments that have led to a reduction in the breast cancer may also have adverse effects on cardiac autonomic balance. The objective of this study was to compare heart rate variability (HRV) between breast cancer survivors in the first year posttreatment and healthy women, controlling for known confounders. This descriptive case-controlled study included 22 breast cancer survivors and 22 healthy age- and sex-matched controls. Short-term HRV was measured using an accepted methodology to assess the cardiac autonomic balance. One-way analysis of covariance results revealed that heart rate was significantly higher (F = 15.86, p < .001) and the standard deviation of normal-to-normal (NN) interval (F = 19.93, p = .001), square root of mean squared differences of successive NN intervals (F = 18.72, p = .001), HRV index (F = 5.44, p = .025), and high-frequency (F = 5.77, p = .03) values were significantly lower in the breast cancer survivors than in the matched controls. The principal finding of the presence of a cardiovascular imbalance in breast cancer survivors in comparison to healthy age-matched controls suggests that HRV study could be a clinically useful tool to detect cardiovascular disease in early-stage breast cancer survivors. © The Author(s) 2015.
Article
Background: Breast cancer survivors (BCS) usually experience musculoskeletal pain and strength imbalance between surgical and nonsurgical sites. Material and methods: This study aimed to assess the effect of handedness and surgical site on pain tolerance and upper extremity strength in BCS. A total of 96 female BCS (Mean age and BMI: 51.06 ± 9.36 years and 27.77 ± 3.75 kg/m2) were included in this study. BCS were categorized as "DoS" or "NoS" whether they had surgery on their dominant or nondominant site, respectively. Socio-demographic data, upper extremity strength, pain tolerance, and pain-related function measurements were performed by simple form, manual muscle tester, pain algometer, and Disabilities of Arm, Shoulder, and Hand's (DASH) pain subscale, respectively. Results: Pain tolerances were significantly lower in upper trapezius muscle region in the surgical site (t = -4,263, P < .001 and t = -2138, P = 0.037) while in the deltoid tuberosity, pain tolerance was significantly higher in surgical site (t = 2633, P = 0.011). Mean differences in strength in shoulder flexion and abduction were significantly lower in the DoS group compared to the NoS group (z = -3.166, P = .002 and z = -2.131, P = .033, respectively), whereas the pain subscale was significantly higher in the DoS (P = .013). Conclusion: Pain tolerance decreased in the upper trapezius muscle region on the surgical site irrespective of the handedness. However, in deltoid tuberosity, the effect of handedness was remarkable. Exercise programs should focus to establish a strength balance in nondominant surgery BCS since strength imbalance might be more prominent to affect them to take part in activities in daily living.
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Evidence for the relationship between chronic pain and nutrition is mounting, and chronic pain following cancer is gaining recognition as a significant area for improving health care in the cancer survivorship population. This review explains why nutrition should be considered to be an important component in chronic pain management in cancer survivors by exploring relevant evidence from the literature and how to translate this knowledge into clinical practice. This review was built on relevant evidence from both human and pre-clinical studies identified in PubMed, Web of Science and Embase databases. Given the relationship between chronic pain, inflammation, and metabolism found in the literature, it is advised to look for a strategic dietary intervention in cancer survivors. Dietary interventions may result in weight loss, a healthy body weight, good diet quality, systemic inflammation, and immune system regulations, and a healthy gut microbiota environment, all of which may alter the pain-related pathways and mechanisms. In addition to being a cancer recurrence or prevention strategy, nutrition may become a chronic pain management modality for cancer survivors. Although additional research is needed before implementing nutrition as an evidence-based management modality for chronic pain in cancer survivors, it is already critical to counsel and inform this patient population about the importance of a healthy diet based on the data available so far.
Article
Objective: Quantitative sensory testing (QST) are non-invasive psychophysical assessment techniques to evaluate functioning of the somatosensory nervous system. Despite the importance of reliability for correct use of QST results in research and clinical practice, the relative and absolute intra-and inter-rater reliability of a comprehensive QST protocol to evaluate the functioning of both peripheral and central somatosensory nervous system in a breast cancer population, has not yet been investigated. Setting: University Hospitals, Leuven, Belgium. Subjects: Thirty women at least six months after unilateral breast cancer surgery. Methods: The protocol included nine static and dynamic QST methods (mechanical detection-pain thresholds, pressure pain thresholds, thermal detection-pain thresholds for heat and cold, temporal summation and conditioned pain modulation (CPM)) performed in the surgical area and more distant regions. Absolute and relative intra (60-minutes interval) and inter-rater (one-week interval) reliability was evaluated using intraclass correlation coefficients, standard error of measurement and Bland-Altman plots. Results: A moderate to excellent relative intra- and inter-rater reliability was found for the evaluation of mechanical thresholds, pressure pain thresholds and temporal summation. Reliability of the CPM paradigm was considered weak. Systematic bias between raters was noticed for detection of mechanical and cold stimuli at the non-affected trunk and CPM. Conclusions: Except for the evaluation of CPM, the QST protocol was found suitable for identifying differences between subjects (relative reliability) and individual follow-up after breast cancer surgery (limited systematic bias) during a one-week timeframe. Additional research is required to determine measurement properties that influence CPM test stability in order to establish a more reliable CPM test paradigm.
Article
The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.
Article
Objectives: Quantitative sensory testing (QST) is a non-invasive technique to evaluate functioning of the somatosensory system. In many women surgically treated for breast cancer (BC), somatosensory functioning is disturbed with high prevalence of sensory loss and/or pain. Aims of this systematic review were (1) to summarize literature about QST methods and (2) results within women surgically treated for BC (patients and survivors); (3) to compare QST results between women surgically treated for BC with and without pain and (4) between women surgically treated for BC and women without history of BC. Methods: A systematic literature search was conducted up to February 2020. Included studies had to report on QST methods (mechanical or thermal detection-pain thresholds, pressure pain thresholds (PPT), temporal summation (TS) or conditioned pain modulation (CPM)) in women over 18 years with-without pain, who had undergone unilateral surgery for BC. Results: Twenty-eight studies were included. Discrepancies in QST methods were greatest for TS and CPM. A local disturbance in thermal detection and an increased pain facilitation were found in BC survivors with pain in the surgical area. BC survivors with upper limb pain had significantly lower PPT at the surgical area and PPT were also significantly lower compared to women without history of BC, at affected and non-affected sides for both local and remote body regions. Discussion: Standardized QST incorporating assessments of CPM is warranted in order to draw conclusions about neurobiological mechanisms of pain and somatosensory disturbances after surgical treatment for BC and to enhance mechanism-based management of these sequelae.
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Article
Introducción: el cáncer de mama (CaM) es uno de los más frecuentes, posee una alta tasa de supervivencia. Los sobrevivientes no solo deben enfrentar la enfermedad y secuelas, sino también, los efectos secundarios de tratamientos oncológicos. El objetivo de esta revisión fue establecer las intervenciones fisioterapéuticas seguras y efectivas para abordar las alteraciones funcionales del complejo articular del Hombro (CAH) que comprometen el rango de movilidad articular (ROM) ipsilateral en mujeres con CaM sometidas a tratamientos oncológicos (cirugía, quimioterapia, radioterapia). Metodología: estudio de revisión bibliográfica narrativa. Se consultaron recursos digitales como PubMed, LILACS, SciELO, Elsevier, RefSeek, Google Académico, Dialnet, Academia, Base, Springer Link, ERIC y Redalyc como fuente de documentos publicados (libros, tesis, artículos científicos). Se utilizaron los descriptores neoplasias de la mama OR radioterapia OR quimioterapia OR mastectomía AND articulación del hombro OR dolor de hombro OR lesiones de hombro, AND fisioterapia OR medicina física OR rehabilitación. Se incluyen documentos publicados durante los últimos 20 años, en español, inglés y portugués. Considerando la evidencia publicada, se proponen algoritmos de intervención fisioterapéutica en la limitación funcional del CAH asociada a tratamiento para el CaM. Resultados: conocidas las principales limitaciones del ROM del CAH en CaM, se establecen las modalidades fisioterapéuticas con respaldo en evidencia científica, para recuperar el ROM y la funcionabilidad del CAH. Algunas de estas son estímulos eléctricos, termoterapia (superficial y profunda), cinesiterapia, fisioterapia invasiva, vendaje neuromuscular y terapia manual. Conclusión: las mujeres con CaM sometidas a tratamientos oncológicos ven afectado el ROM del CAH. La fisioterapia ayuda a mitigar estas secuelas.
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Article
Introducción En cáncer de mama es uno de los más frecuentes en mujeres, trae consigo varias complicaciones postratamiento. Una de ellas es el síndrome de mama fantasma dolorosa (SdMFD), que es la experiencia subjetiva de percibir y detectar la presencia de toda o parte de la mama acompañado de dolor. En Costa Rica, no se cuenta con un protocolo ni guía para el abordaje fisioterapéutico en mujeres con SdMFD. Objetivo: Establecer las características fisiopatológicas del SdMFD para lograr su comprensión y así elaborar una propuesta de intervención fisioterapéutica basándose en los efectos de los agentes físicos en el cuerpo. Materiales y métodos: Estudio descriptivo de revisión bibliográfica, considerando recursos digitales tales como Pubed, LILACS, Scielo, Elsevier, RefSeek, Google Académico, Dialnet, Academia, Base, Springer Link, ERIC y Redalyc como fuente de documentos (libros, tesis, artículos científicos) publicados, utilizando como descriptores las palabras neoplasia de la mama OR mastectomía OR síndrome de miembro fantasma OR cirugía OR dolor postoperatorio OR dolor en cáncer, AND fisioterapia OR rehabilitación. Se incluyen documentos publicados desde el año 1990 al 2020, en español, inglés y portugués. Con base en la evidencia publicada se proponen algoritmos intervención de fisioterapéutica en mujeres con SdMFD. Resultados: Conociendo la fisiopatología del SdMFD, se establecen las modalidades fisioterapéuticas con evidencia y respaldo científico que se pueden utilizar de manera segura, bajo criterio y conocimiento profesional para abordar este síndrome o síndromes similares como el dolor fantasma. Se recomiendan el TENS (estimulación eléctrica transcutánea), termoterapia superficial y crioterapia como técnicas fisioterapéuticas para tratar el dolor; además algunas técnicas manuales como liberación de puntos gatillo, masaje terapéutico y neurodinámica para tratar tejido miofascial y nervioso afectado por la cirugía; así como el uso de vendaje neuromuscular para mejorar la mecanosensibilidad afectada en las mujeres con este síndrome. Conclusión: el fisioterapeuta con conocimiento en rehabilitación oncológica puede generar grandes aportes en la salud y calidad de vida de mujeres con SdMFD, utilizando de forma segura y con evidencia científica que lo respalde varias técnicas fisioterapéuticas.
Article
Background: Lung cancer is the leading cause of cancer death worldwide, and lung resection still represents the main curative treatment modality. Although video-assisted thoracoscopic surgery has emerged as a minimally invasive alternative, its relationship with shoulder musculoskeletal signs remains unclear. Objective: To characterize shoulder dysfunction in patients after video-assisted thoracoscopic surgery and to analyze its influence on quality of life. Design and setting: A longitudinal observational prospective cohort study has been carried out in the Thoracic Surgery Service of the Hospital Virgen de las Nieves (Granada). Subjects: Fifty-nine patients undergoing video-assisted thoracoscopic surgery were included. Methods: Patients were assessed before surgery, at discharge, and one month after discharge. Musculoskeletal disturbances, pain severity, and health status were assessed. Musculoskeletal outcomes measured were range of movement and trigger points, both bilaterally. Additionally, pain severity and health status were measured with Brief Pain Inventory and Euroqol-5 dimensions. Results: Significant differences were found at discharge in trigger points of ipsilateral and contralateral upper limbs. One month after surgery, no muscle returned to baseline measures, and ipsilateral and contralateral shoulders presented a decreased range of motion, as well as poor quality of life and high severity and interference of pain. Conclusions: Video-assissted thoracoscopic surgery was associated with musculoskeletal shoulder dysfunction, which remained one month after the intervention. This musculoskeletal dysfunction included significant dysfunction in both shoulders with a decreased range of movement, an increase in trigger points, poor quality of life, and high severity and interference of pain.
Article
Objective: The purpose of this systematic review was to investigate the effectiveness of manual therapy (MT) for chronic musculoskeletal pain (CMP) in the upper limbs and thorax of female breast cancer survivors and to investigate the changes in the quality of life and function of these patients. Methods: Systematic searches were performed in the databases MEDLINE/PubMed, Cumulative Index of Nursing and Allied Health/EBSCO, Web of Science, and Physiotherapy Evidence Database, through March 2018, to identify randomized controlled trials investigating whether MT was effective to treat CMP pain in female breast cancer survivors (PROSPERO number CDR42017074175). Results: The database searches retrieved 1562 titles, and after screening, 5 papers were included for full analysis. The manual therapy techniques described in the included studies involved myofascial induction, myofascial release, classic massage, ischemic compression of trigger points, and myofascial therapy. A meta-analysis, using a fixed-effects model, found that MT decreased CMP intensity (standardized mean difference: 0.32; 95% CI 0.06-0.57), but no significant difference was observed in quality of life after the MT intervention in comparison with a control condition (standardized mean difference: 0.14; 95% CI 0.17-0.46). Conclusion: Current evidence suggests that MT is considered effective for treating CMP in the upper limbs and thorax of female breast cancer survivors.
Article
Résumé Vingt-cinq à soixante-cinq pour cent des patientes présentent une douleur chronique après cancer du sein. Le traitement associe médicaments antalgiques et techniques psychocorporelles. Hypothèse L’ostéopathie améliore le contrôle des douleurs et la qualité de vie des patientes. Méthode Étude randomisée prospective monocentrique comparant un traitement antalgique standard (bras A) à un traitement antalgique standard + ostéopathie, débuté entre un et douze mois après la chirurgie. Objectif principal Intensité de la douleur (EVA à trois mois [j90]). Objectifs secondaires Douleur (EVA) à six et douze mois, consommation d’antalgiques, anxiété/dépression (HADS-Hospital Anxiety and Depression Scale), qualité de vie (QLQ-C30). Quatre-vingt patientes prévues pour une différence EVA de deux points (alpha bilatéral 5 %, puissance 90 %). Résultats Vingt-huit patientes (14 par bras) ont été incluses d’avril 2011 à février 2014, imposant l’arrêt de l’étude. À j90, le niveau de douleur à l’EVA n’était pas différent entre les deux bras (p = 0,258), de même qu’à six et douze mois. L’évolution du score de dépression HADS entre l’inclusion et j90 était plus favorable dans le bras B (p = 0,049). Le score global de qualité de vie était meilleur dans le bras B à j90 (p = 0,015), ainsi que le sous-score douleur (p = 0,021). Discussion Les patientes sont demandeuses de thérapies complémentaires. Peu d’études existent. Notre étude s’est heurtée à des difficultés majeures de recrutement, ce qui limite l’interprétation des résultats. Malgré l’absence de différence sur l’objectif principal, des éléments (QV, dépression) sont à noter en faveur de l’ostéopathie. Des études multicentriques sont nécessaires.
Article
The goal of this study was to study central sensitization (CS)‐related symptoms in breast cancer (BC) survivors and to find if there are differences in clinical and functional variables. In this cross‐sectional study, 25 women aged between 32 and 69 years participated. CS pain was measured with the Central Sensitization Inventory (CSI). Forty points was considered the cutoff value. Cancer‐related fatigue (CRF), Quality of life, functional capacity, and handgrip strength (HGS) was assessed. A 60% of BC survivors showed a CSI score from 0 to 40, while the rest 40% of women had a score higher than 40, CSI scores being 38.35 ± 14.54 points in the whole sample. Significant differences were found in functional capacity, CRF and QoL (p < .011). However, there were no differences in HGS (p = .089). This is the first study to report BC survivors CS‐related symptoms. The high CS‐related symptoms group showed differences in some symptoms and functional capacity in this population. Future research including a wider sample and more variables related to pain should be carried out.
Article
Objective: To investigate somato-sensory nerve fibre function by applying different quantitative sensory testing including thermal, mechanical and vibration thresholds over latent trigger points (TrP) and in its associated referred pain area. Methods: A total of 20 subjects with unilateral latent TrPs in the extensor carpi radialis brevis were included. Warmth detection threshold (WDT), cold detection threshold CDT) and heat/cold pain thresholds (HPT, CPT), mechanical detection (MDT) and pain (MPT) thresholds, vibration threshold (VT), and pressure pain thresholds (PPT) were blinded assessed over the TrP, in the referred pain area, and in the respective contra-lateral mirror areas. A multilevel mixed-model ANOVA with site (TrP, referred pain area) and side (real or contra-lateral) as within-subjects factors and gender as between-subjects factor was conducted. Results: No significant differences for thermal detection (WDT, CDT) or thermal pain thresholds (HPT, CPT) were found (all, P>0.141). The assessments over the TrP area showed lower PPT and MDT compared to the mirror contra-lateral TrP area (P<0.05). MDT were higher (P=0.001) but PPT (P<0.001) and MPT (P=0.032) were lower over the TrP area and contra-lateral mirror point compared to their respectively referred pain areas. Finally, VT was higher over the TrP area than in the referred pain area and over both mirror contra-lateral points. Discussion: Assessing sensory changes over latent myofascial TrPs reveal mechanical hyperesthesia, pressure pain hyperalgesia, and vibration hypoesthesia compared to a contra-lateral mirror area.
Article
Objective: assess the effects of ischemic compression and kinesiotherapy on the rehabilitation of breast cancer survivors with chronic myofascial pain. Methods: A randomized, controlled, blinded clinical trial was performed with 20 breast cancer survivors with myofascial trigger point in the upper trapezius muscle. Patients were randomly allocated to ischemic compression + kinesiotherapy (G1, n = 10) and kinesiotherapy (G2, n = 10). Both groups were submitted to 10 sessions of treatment. The variables evaluated were: Numeric Rating Scale, Pain Related Self-Statement Scale, pressure pain threshold, Functional Assessment of Cancer Therapy-Breast and Infrared thermography. Results: A significant reduction (p < 0.05) was observed in pain intensity after 10 sessions in Groups 1 and 2, a significant increase (p < 0.05) in pressure pain threshold in both the operated and non-operated side after 10 sessions for Group 1. Conclusion: Ischemic compression associated with kinesiotherapy increases the pressure pain threshold on the myofascial trigger point in the upper trapezius muscle and reduces the intensity of pain in breast cancer survivors with myofascial pain.
Chapter
Si l’on peut supposer raisonnablement que certaines chirurgies induisent des lésions nerveuses périphériques (cf. infra), on connaît en revanche très mal la nature exacte des lésions. Les gestes pratiqués en cours de chirurgie sont en faveur de trois types de lésions possibles: — la section d’une branche terminale de petite taille, le chirurgien évitant a priori de léser ce qui lui est évident visuellement ; cette section peut générer un névrome inducteur de douleur provoquée et/ou une sensation de «pièce manquante fantôme» liée à la déafférentation; — l’écrasement: c’est ce qui est classiquement observé en cours de thoracotomie [1] ; — le «piégeage» (entrapment) du nerf lors de la cicatrisation, notamment au sein de la fibrose réactionnelle.
Chapter
Neuroplasticity is a term that is used quite frequently these days in pain-related literature, and in many ways, it has come to be a term especially associated with maldynia. However, neuroplasticity is a term that more accurately delineates the way our nervous system operates, peripherally and centrally, and it should have no intrinsic judgment placed upon it. It simply is what it is.
Chapter
Chronische pijnpatiënten vormen een heterogene populatie. Het mag duidelijk zijn dat niet alle chronische pijnpatiënten per definitie een klinisch beeld hebben dat gedomineerd wordt door centrale sensitisatie. Bij medische diagnosen zoals whiplash, fibromyalgie, prikkelbaredarmsyndroom en het chronischevermoeidheidssyndroom, vertonen patiënten typisch dominante centrale sensitisatiepijn. Bij atraumatische chronische nekpijn is er echter weinig tot geen bewijs voor de aanwezigheid van centrale sensitisatie. Patiënten met artrose, tenniselleboog, schouderpijn en lage rugpijn zijn groepen pijnpatiënten waarvan de minderheid een klinisch beeld vertoont dat gedomineerd wordt door centrale sensitisatie. Daarom is goede differentiaaldiagnostiek noodzakelijk. In dit hoofdstuk reiken we de clinicus praktijkrichtlijnen aan voor de differentiaaldiagnostiek tussen de drie grote pijntypen: dominant nociceptieve, neuropathische en centrale sensitisatiepijn. De klinische werkmethode voor de differentiaaldiagnostiek tussen dominant nociceptieve, neuropathische en centrale sensitisatiepijn bestaat uit twee stappen:1. de diagnostiek of uitsluiting van de aanwezigheid van dominant neuropathische pijn; 2. de differentiaaldiagnostiek tussen dominant nociceptieve en centrale sensitisatiepijn. Stap 2 omvat het screenen van drie criteria aan de hand van een beslisboom. In het laatste deel van het hoofdstuk worden deze criteria toegepast op en gespecificeerd voor (1) de lage rugpijnpopulatie en (2) pijn bij/na kanker.
Article
Objectives: To evaluate widespread pressure pain in patients with chronic plantar heel pain compared with that in healthy controls and to investigate the differences in ultrasound imaging and quality of life between these two groups. Methods: A total of 22 patients (11 female) with chronic plantar heel pain and the same number of healthy patients, matched according to age and gender, were included in this pilot study. Pressure pain thresholds (PPTs) were bilaterally assessed over the calcaneus bone, the plantar fascia, the first and fifth metatarsals, the soleus muscle, the second metacarpal, and the zygapophyseal joint of C5-C6. Plantar fascia thickness was measured via ultrasound imaging. In addition, quality of life and physical function were assessed using the Short-Form 36 (SF-36) questionnaire and the Foot and Ankle Ability Measure (FAAM) questionnaire, respectively. Results: Analysis of covariance (ANCOVA) results showed significant differences in the PPTs at all points between the groups (P < 0.001), but not between sides. The PPTs were significantly lower in the patients than in the controls at all sites (P < 0.05). The results showed significant increases in fascia thickness at the calcaneus insertion (group: F = 74.172, P ≤ 0.001; side: F = 8.920, P ≤ 0.001) and the middle fascia point (group: F = 133.685, P = <0.001; side: F = 11.414, P = <0.001) on ultrasound in the patient group compared with the matched control group. The analysis also revealed that the patient group had a significantly lower score on every subscale of the SF-36 and FAAM questionnaires (all P < 0.001), except for the mental component, compared with the matched control group. Discussion: Patients suffering from chronic plantar heel pain showed widespread and bilateral hypersensitivity, increased thickness of the plantar fascia in the affected foot, and deterioration in quality of life and physical functioning compared with matched controls.
Article
Although the concept of chronic postsurgical pain (CPSP) involves a number of different pathophysiological contexts, it appears that injury to a peripheral nerve trunk (mononeuropathy) is a major causal factor. A binary process to separate out these mechanisms as far as possible would seem to be useful in order to gain more knowledge about the mechanisms involved, since the key challenge is to develop preventative measures. Some types of surgery are considered to be associated with specific types of nerve trunk damage, which at least account for the neurological deficits found during assessments in the medium term but are not necessarily associated with neuropathic-type pain symptoms. Nerve injury thus appears to be an essential but not sufficient factor for the development of CPSP, while other factors, mostly genetic and biographical in nature, are superimposed upon it. © 2014 Springer International Publishing Switzerland. All rights reserved.
Article
Mechanism-based classification (MBC) of pain comprised of five mechanisms: cognitive-affective, central sensitization, peripheral sensitization, sympathetically maintained pain, and nociceptive. The objective of this editorial was to provide an overview on central sensitization and its implications for PT evaluation and management of central sensitivity syndromes associated with common clinical presentations.
Chapter
Neuroplasticity is a term that is used quite frequently these days in pain-related literature, and in many ways, it has come to be a term especially associated with maldynia. However, neuroplasticity is a term that more accurately delineates the way our nervous system operates, peripherally and centrally, and it should have no intrinsic judgment placed upon it. It simply is what it is.
Article
Resumen Objetivo Determinar la calidad de vida, el estado musculoesquelético y el dolor en pacientes diagnosticados de cáncer de colon, previamente a cirugía. Material y métodos Un total de 15 pacientes con cáncer de colon y 15 controles sanos formaban la muestra del estudio transversal. La calidad de vida se evaluó a través del cuestionario QLQ-C30. El resto de variables se valoró mediantes el test de McQuade, dinamometría de tronco, algometría para los umbrales de dolor a la presión y una escala visual analógica. Se realizó un análisis principal mediante la covarianza ANCOVA. Resultados Se encontraron diferencias significativas en la calidad de vida entre pacientes diagnosticados con cáncer de colon y los controles sanos en la función física (p < 0,01), tareas (p < 0,01), función emocional (p = 0,046), fatiga (p < 0,01), dolor (p = 0,05), insomnio (p = 0,04), apetito (p = 0,01), diarrea (p = 0,01) y salud global (p < 0,01). Mediante las imágenes ecográficas se encontró una disminución del grosor de los músculos oblicuo interno (p = 0,02) y del transverso del abdomen (p = 0,02) entre ambos grupos de estudio. No hubo cambios significativos en el resto de variables estudiadas. Conclusiones Los pacientes diagnosticados de cáncer de colon presentan, previamente a la cirugía, un deterioro de la calidad de vida y alteraciones musculoesqueléticas de la musculatura profunda estabilizadora del abdomen. Los grupos de estudio no presentan cambios significativos con relación al dolor.
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PURPOSE: This study investigated short-term changes in body composition, handgrip strength, and presence of lymphedema in women who underwent breast cancer surgery. METHODS: Ninety-five women participated in a cross-sectional study, divided into two groups: Control (n=46), with healthy women, and Experimental (n=49), with women six months after breast cancer surgery . The Experimental Group was subdivided into right total mastectomy (RTM, n=15), left total mastectomy (LTM, n=11), right quadrant (RQ, n=13), and left quadrant (LQ, n=10). It was also redistributed among women with presence (n=10) or absence (n=39) of lymphedema. Presence of lymphedema, handgrip strength, and body composition were assessed. RESULTS: Trunk lean mass and handgrip strength were decreased in the Experimental Group. Total lean mass was increased in the LTM compared to RTM or LQ. Left handgrip strength in LTM was decreased compared to RTM and RQ and in LQ compared to RTM and RQ. Finally, total lean mass, trunk fat mass, trunk lean mass, right and left arm lean mass were increased in women with lymphedema. CONCLUSIONS: Breast cancer survivors have changes in their body composition and in handgrip strength six months after surgery; however, the interaction between the type of surgery and its impact is unclear. Furthermore, women who developed lymphedema in this period showed more significant changes in the body composition, but they were not enough to cause impairment in handgrip strength.
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Article
To update the pattern of cancer mortality in Europe. Materials and methods: We analysed cancer mortality in 34 European countries during 2000-2004, with an overview of trends in 1975-2004 using data from the World Health Organization. From 1990-1994 to 2000-2004, overall cancer mortality in the European Union declined from 185.2 to 168.0/100 000 (world standard, -9%) in men and from 104.8 to 96.9 (-8%) in women, with larger falls in middle age. Total cancer mortality trends were favourable, though to a variable degree, in all major European countries, including Russia, but not in Romania. The major determinants of these favourable trends were the decline of lung (-16%) and other tobacco-related cancers in men, together with the persistent falls in gastric cancer, and the recent appreciable falls in colorectal cancer. In women, relevant contributions came from the persistent decline in cervical cancer and the recent falls in breast cancer mortality, particularly in northern and western Europe. Favourable trends were also observed for testicular cancer, Hodgkin lymphomas, leukaemias, and other neoplasms amenable to treatment, though the reductions were still appreciably smaller in eastern Europe. This updated analysis of cancer mortality in Europe showed a persistent favourable trend over the last years.
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Since the 1980s, Spain experienced two decades of sharply increasing breast cancer incidence. Declines in breast cancer incidence have recently been reported in many developed countries. We examined whether a similar downturn might have taken place in Spain in recent years. Cases of invasive female breast cancer were drawn from all population-based Spanish cancer registries that had at least 10 years of uninterrupted registration over the period 1980-2004. Overall and age-specific changes in incidence rates were evaluated using change-point Poisson models, which allow for accurate detection and estimation of trend changes. All statistical tests were two-sided. A total of 80,453 incident cases of invasive breast cancer were identified. Overall age- and registry-adjusted incidence rates rose by 2.9% (95% confidence interval [CI] = 2.7% to 3.1%) annually during the 1980s and 1990s; there was a statistically significant change in this trend in 2001 (95% CI = 1998 to 2004; P value for the existence of a change point <.001), after which incidence declined annually by 3.0% (95% CI = 1.8% to 4.1%). This trend differed by age group: There was a steady increase in incidence for women younger than 45 years, an abrupt downturn in 2001 for women aged 45-64 years, and a gradual leveling off in 1995 for women aged 65 years or older. Separate analyses for registries that had at least 15 years of uninterrupted registration detected a statistically significant interruption of the previous upward trend in breast cancer incidence in provinces that had aggressive breast cancer screening programs and high screening participation rates, including Navarra (change point = 1991, P < .001), Granada (change point = 2002, P = .003), Bizkaia (change point = 1998, P < .001), Gipuzkoa (change point = 1998, P = .001), and Araba (change point = 1997, P = .002). The recent downturn in breast cancer incidence among Spanish women older than 45 years is best explained by a period effect linked to screening saturation.
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The aim of this study was to investigate whether bilateral widespread pressure hypersensitivity exists in patients with unilateral carpal tunnel syndrome. A total of 20 females with carpal tunnel syndrome (aged 22-60 years), and 20 healthy matched females (aged 21-60 years old) were recruited. Pressure pain thresholds were assessed bilaterally over median, ulnar, and radial nerve trunks, the C5-C6 zygapophyseal joint, the carpal tunnel and the tibialis anterior muscle in a blinded design. The results showed that pressure pain threshold levels were significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the carpal tunnel, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with unilateral carpal tunnel syndrome as compared to healthy controls (all, P < 0.001). Pressure pain threshold was negatively correlated to both hand pain intensity and duration of symptoms (all, P < 0.001). Our findings revealed bilateral widespread pressure hypersensitivity in subjects with carpal tunnel syndrome, which suggest that widespread central sensitization is involved in patients with unilateral carpal tunnel syndrome. The generalized decrease in pressure pain thresholds associated with pain intensity and duration of symptoms supports a role of the peripheral drive to initiate and maintain central sensitization. Nevertheless, both central and peripheral sensitization mechanisms are probably involved at the same time in carpal tunnel syndrome.
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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.
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Few studies have focused on careful assessment of postmastectomy pain (PMP); a chronic neuropathic pain syndrome that can affect women postlumpectomy or postmastectomy for breast cancer (BC). Study aims were to determine the prevalence of PMP in an outpatient sample of breast cancer survivors (BCS), describe subjective and objective characteristics of PMP, and examine the relationship between PMP and quality of life. Breast cancer survivors (n = 134) participated in telephone interviews, and those reporting PMP (n = 36) were invited to a pain center for further evaluation and treatment. Results show PMP is a distinct, chronic, pain syndrome affecting 27% of BCS. Findings support the need for clinical trials evaluating the effectiveness of nonpharmacological or cognitive behavioral therapies in alleviating mild to moderate PMP.
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The prevalence of rheumatoid symptoms following breast cancer (BC) treatment was examined. Breast cancer patients (n = 111) who were a mean of 27.6 months postcompletion of BC treatment and 99 otherwise healthy women with benign breast problems (BBP) completed a self-report measure that assessed current joint pain, swelling, and stiffness, as well as measures of quality of life. Results supported a hypothesized link between BC and rheumatoid symptoms: (1) the BC group was more likely to report joint stiffness lasting more than 60 min following morning waking; (2) the prevalence of unilateral or bilateral joint point or swelling was greater (P < 0.10) in the BC group for four of 10 joint-symptom combinations examined, with differences between the BC and BBP groups in upper extremity joint swelling particularly pronounced; and (3) 41% of the BC group reported that current rheumatoid symptoms exceeded those experienced prior to diagnosis. Within the BC group, the data did not support postchemotherapy rheumatism as an explanation for rheumatoid symptoms. Rather, data suggested that symptoms were associated with surgical management of BC. Finally, among women in the BC group with the most severe joint pain, only a minority were receiving medication for these symptoms. Given the relationship between rheumatoid symptoms and quality of life, more systematic research examining potential contributing factors such as menopausal status, concurrent lymphedema, and weight gain is warranted.
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The pressure pain threshold (PPT), i.e. the least stimulus intensity at which a subject perceives pain, was studied in 30 patients with chronic unilateral pain in the shoulder and arm region.Fourteen trigger points were investigated on both sides of the body using pressure algometry. Eight paravertebral points and six points in the shoulder and arm region were evaluated. Each location was examined twice. The patients were tested by one examiner.The intraobserver reliability of PPT measurements was considered to be good. The Intraclass Correlation Coefficients of reliability (ICC), based on two repeated PPT measurements varied between 0.64 and 0.96. The painful side of the body was found to be more sensitive than the non-painful side, although there was not always a significant difference at the 0.05 level. The PPT was found to be higher in males than in females (P < 0.05). Females demonstrated lower PPTs than males at each trigger point. It was established that pressure tenderness varies over individual trigger points. Significant regional differences in PPT values were observed (P < 0.05). PPT values decreased in a cranial direction in the spine and in a caudal direction in the upper limb.Although the authors expected to find segmentally reduced PPT values on the painful side of the body, a generalized reduction of PPT values was present at all peripheral and spinal segmental sites. Some correlations between segmentally related trigger points were found by factor analysis. Copyright 1996 Harcourt Publishers Ltd.
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IN the dorsal part of the dorsal horn there is a lamina of cells which respond to cutaneous stimulation and send their axons into the dorsolateral tract. In previous investigations1 it was apparent that many different types of A fibres converged on these cells. It is, therefore, interesting to see whether C fibres also affect their firing. In a recent investigation2 it was found that an afferent volley in the unmyelinated fibres led to a positive dorsal root potential as opposed to the well-known negative dorsal potential which is elicited by the large myelinated fibres. It was suggested that C fibres led to presynaptic hyperpolarization which would produce facilitation as contrasted with the presynaptic inhibitory effects of the A fibres. An investigation of the ventral root reflex (VRR, ref. 2) showed no late component which could be attributed to C fibres; however, a tetanus in the C's was found to potentiate the VRR elicited by the A fibres in the same peripheral nerve. It was also known that a large stimulus to a peripheral nerve led to late discharges in various midbrain and forebrain structures3. With these factors in mind an investigation of the response of cells in the dorsolateral tract of the cat to C fibres was carried out.
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This is the first reported description, to the author's knowledge, of myofascial pain occurring at a surgical drain site. The patient consulted a medical acupuncturist after suffering five months of continuous chest and arm pain associated with 'tingling' in the forearm and hand. She had undergone trans-axillary resection of the first left rib following a left axillary vein thrombosis 18 months previously. Her symptoms had been principally attributed to nerve traction at surgery or nerve root entrapment from scar tissue. However, the drain passed through the free border of pectoralis major, and the myofascial trigger point that appeared to develop as a result of the muscle trauma, or the pain at that site, presented as a chronic and complex post-surgical pain problem. The pain and tingling resolved completely after two sessions of dry needling at a single myofascial trigger point in the free border of the left pectoralis major muscle.
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The aim of this study was to assess impairments, disabilities and health related Quality of Life (QOL) after treatment of breast cancer and to analyse the relationship between treatment modalities, impairments, disabilities and health related QOL. Fifty-five patients who underwent a modified radical mastectomy or a segmental mastectomy with axillary lymph node dissection were retrospectively assessed with a mean follow up of 2.7 years after treatment. Impairments were assessed by means of measuring active shoulder range of motion, grip strength, arm volume and pain. Disabilities were assessed by means of the Shoulder Disability Questionnaire (SDQ) and health related QOL was assessed by means of the RAND 36-item Health Survey (RAND-36). University Hospital Groningen (The Netherlands). Pain (60%) and reduction of grip-strength (40%) were the most frequent impairments found. The prevalence of impaired range of motion and oedema was 9 - 16% respectively 15%. Mean group score of the SDQ was 33.7 (sd: 32.1) and mean scores of the RAND-36 differed significantly for physical functioning, vitality and health perception to that of a female norm group. Radiotherapy and chemotherapy were significant factors in the prediction of impaired range of motion. Pain and restricted range of motion explained 61% respectively 12% of the variance in disability (SDQ). In the prediction of health related QOL, pain, grip strength and arm volume were significant factors respectively in six, three and two domains. Pain is the most frequent assessed impairment after breast cancer treatment with strong relationship to perceived disability and health related QOL. Disability is mild and health related QOL (RAND-36) differed in three of the nine domains with a female norm group.
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Many patients suffer from severe shoulder complaints after breast cancer surgery and axillary lymph node dissection. Physiotherapy has been clinically observed to improve treatment of these patients. However, it is not a standard treatment regime. The purpose of this study is to investigate the efficacy of physiotherapy treatment of shoulder function, pain and quality of life in patients who have undergone breast cancer surgery and axillary lymph node dissection. Thirty patients following breast cancer surgery and axillary lymph node dissection were included in a randomised controlled study. Assessments were made at baseline and after three and six months. The treatment group received standardised physiotherapy treatment of advice and exercises for the arm and shoulder for three months; the control group received a leaflet containing advice and exercises. If necessary soft tissue massage to the surgical scar was applied. Primary outcome variables were amount of pain in the shoulder/arm recorded on the Visual Analogue Scale, and shoulder mobility (flexion, abduction) measured using a digital inclinometer under standardized conditions. Secondary outcome measures were shoulder disabilities during daily activities, edema, grip strength of both hands and quality of life. The researcher was blinded to treatment allocation. All thirty patients completed the trial. After three and six months the treatment group showed a significant improvement in shoulder mobility and had significantly less pain than the control group. Quality of life improved significantly, however, handgrip strength and arm volume did not alter significantly. Physiotherapy reduces pain and improves shoulder function and quality of life following axillary dissection after breast cancer.
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To investigate the biochemical milieu of the upper trapezius muscle in subjects with active, latent, or absent myofascial trigger points (MTPs) and to contrast this with that of the noninvolved gastrocnemius muscle. We used a microanalytic technique, including needle insertions at standardized locations in subjects identified as active (having neck pain and MTP), latent (no neck pain but with MTP), or normal (no neck pain, no MTP). We followed a predetermined sampling schedule; first in the trapezius muscle and then in normal gastrocnemius muscle, to measure pH, bradykinin, substance P, calcitonin gene-related peptide, tumor necrosis factor alpha, interleukin 1beta (IL-1beta), IL-6, IL-8, serotonin, and norepinephrine, using immunocapillary electrophoresis and capillary electrochromatography. Pressure algometry was obtained. We compared analyte concentrations among groups with 2-way repeated-measures analysis of variance. A biomedical research facility. Nine healthy volunteer subjects. Not applicable. Preselected analyte concentrations. Within the trapezius muscle, concentrations for all analytes were higher in active subjects than in latent or normal subjects (P<.002); pH was lower (P<.03). At needle insertion, analyte concentrations in the trapezius for the active group were always higher (pH not different) than concentrations in the gastrocnemius muscle. At all times within the gastrocnemius, the active group had higher concentrations of all analytes than did subjects in the latent and normal groups (P<.05); pH was lower (P<.01). We have shown the feasibility of continuous, in vivo recovery of small molecules from soft tissue without harmful effects. Subjects with active MTPs in the trapezius muscle have a biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different from subjects with latent or absent MTPs in their trapezius. These concentrations also differ quantitatively from a remote, uninvolved site in the gastrocnemius muscle. The milieu of the gastrocnemius in subjects with active MTPs in the trapezius differs from subjects without active MTPs.
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Axillary dissection in combination with radiation therapy is thought to be the main reason why patients surgically treated for breast cancer may develop decreased shoulder mobility on the operated side. The surgery performed on the breast has not been ascribed any considerable importance. In order to evaluate the influence of the surgical technique and the adjuvant oncological therapy on the development of shoulder morbidity, we assessed the physical disability in 132 breast cancer patients with a median follow-up time of 3 years after surgery. Eighty nine (67%) patients had been subjected to modified radical mastectomy and 43 (33%) to breast conserving therapy (BCT). All patients had axillary dissection of level I and II. The shoulder function was assessed by the Constant Shoulder Score including both subjective parameters on pain and ability to perform the normal tasks of daily living, and objective parameters assessing active range of motion and muscle strength. Shoulder disability seems to be a frequent late complication to the treatment of early breast cancer (35%). When equal axillary dissection and radiation therapy had been applied, BCT patients were found to suffer less frequent from this complication than patients treated with mastectomy.
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This annual report to the nation addresses progress in cancer prevention and control in the U.S. with a special section on colorectal cancer. This report is the joint effort of the American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS).
Chapter
Die vom ACR 1990 festgelegten diagnostischen Kriterien der Fibromyalgie umschreiben diese Erkrankung de facto als ein Syndrom, das durch diffuse Schmerzen sowie durch zahlreiche schmerzhafte Druckpunkte gekennzeichnet ist. Vorherrschend sind Schmerzen in der axialen Skelettmuskulatur, und als maßgebende Symptome werden Müdigkeit, Steifigkeit sowie Schlafstörungen festgestellt. Eine Fibromyalgie läßt sich aufgrund einfacher Kriterien (diffuse Schmerzen und Vorliegen von 11 der insgesamt 18 schmerzhaften Druckpunkte) von ähnlichen Beschwerden in der Skelettmuskulatur unterscheiden. Zuverlässige Diagnosen sind ohne Berücksichtigung psychischer Merkmale und ohne Notwendigkeit von Labor- oder Röntgenuntersuchungen möglich. In diagnostischer Hinsicht weisen primäre und sekundäre bzw. begleitende Fibromyalgien keine Unterschiede auf. Deshalb kann und sollte eine Fibromyalgie auch bei Vorliegen anderer Erkrankungen der Skelettmuskulatur sowie bei Störungen außerhalb der Skelettmuskulatur diagnostiziert werden, d. h. sie stellt keine Ausschlußdiagnose dar. Die Diagnose ist einfach und absolut keine geheimnisvolle Angelegenheit: Sie erfordert lediglich anamnestische Daten sowie unkomplizierte körperliche Untersuchungsmetho¬den. Solche Untersuchungen sollten ebenso häufig vorgenommen werden wie Gelenkuntersuchungen.
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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.
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Chronic pain, lymphoedema, post-irradiation neuropathy and other symptoms are reported in as many as 75% of women following breast cancer treatment. This study examined pain and sensory abnormalities in women following breast cancer surgery. Sensory tests were carried out on operated and contralateral sides in 15 women with spontaneous pain and sensory abnormalities and 11 pain-free women. Testing included the VAS score of spontaneous pain, detection and pain threshold to thermal and mechanical stimuli, temporal summation to repetitive heat and pinprick stimuli, and assessment of skin blood flow during repetitive brush and pinprick stimulation. Sensory threshold to pinprick and thermal stimuli was significantly higher on the operated side in both groups while pressure pain threshold was significantly lower in pain patients on the operated side compared to the contralateral side. No side to side difference was seen in pressure pain threshold in the pain-free group. Evoked pain intensity to repetitive stimuli at 0.2 and 2.0 Hz was significantly higher on the operated side in pain patients compared to the control area while no such difference was seen in pain-free patients. Cutaneous blood flow measured by laser Doppler (flux) was significantly higher when the skin was tapped at 2.0 Hz on the operated side compared to contralaterally in pain patients, while no side to side difference was seen in pain-free patients. Pinprick-evoked pain was correlated to spontaneous pain but not to flux. Spontaneous pain was not correlated to flux. Sensitization seems to be a feature in breast cancer-operated women with pain, but not in pain-free women.
Article
The paradoxical combination of sensory loss within the area where pain is felt together with pain evoked by non-noxious stimuli (allodynia) is a characteristic feature of neuropathic pain. This study examined the relationship between (mechanical and thermal) pain thresholds and dynamic and static hyperalgesia in 15 patients with traumatic nerve injury and brush-evoked pain. Sensory tests were carried out both in the allodynic skin area and in the unaffected contralateral mirror image skin. The sensory characteristics included: visual analogue scale (VAS) score of ongoing pain, detection and pain threshold to thermal and mechanical stimuli, and temporal summation to repetitive heat and pinprick stimuli. Temporal summation was evoked by pinprick stimuli at 2.0 Hz but not at 0.2 Hz in allodynic skin. No difference was observed in temporal summation to heat stimuli. There was a significant and inverse relation between heat and cold pain difference and mechanically evoked pain. Patients with heat hyperalgesia had a significantly higher VAS score of mechanical hyperalgesia than patients with heat hypoalgesia. There was no relationship between dynamic and static evoked hyperalgesia. These findings suggest a differential processing of repetitive thermal and mechanical stimuli in the central nervous system. Both dynamic and static mechanical hyperalgesia are maintained by activity in heat-sensitive nociceptors, but they are probably mediated by distinct mechanisms.
Article
To investigate in patients with repetitive strain injury (RSI) and in office workers using computer keyboard equipment (a) whether the vibration threshold in the hand was altered, (b) the immediate effects of keyboard use on vibration thresholds and (c) whether the tolerance of suprathreshold vibration was normal. A vibrametre (Somedic Ab, Stockholm Sweden) was used to obtain threshold vibration measurements, by the method of limits, for all peripheral-nerve cutaneous distributions in the hand. Tolerance of suprathreshold stimulation was obtained by stimulation of the soft tissues of the forearm by increasing the amplitude of vibration. Thresholds for vibration were significantly raised for the median nerve in both the patient and office-worker groups. The patient group additionally had raised thresholds for the ulnar nerve. Following use of the keyboard, thresholds for the median nerve were further elevated in the patient group, but not in the other groups, demonstrating a work-related exacerbation. At suprathreshold stimulation. 14 members (82%) of the patient group experienced an allodynic response to vibration, indicating, possible changes in the central processing of non-noxious sensory information. This changed sensory response was not seen in either the office-worker or control groups. Patients may have a minor polyneuropathy, whereas the office workers demonstrate early signs of the condition. Quantitative measurement of vibration perception may prove useful in patient assessment and for detection of the early onset of RSI in the work environment.
Article
The generalized hypersensitivity associated with fibromyalgia syndrome (FMS) may in part be driven by peripheral nociceptive sources. The aim of the study was to investigate whether local and referred pain from active myofascial trigger points (MTrPs) contributes to fibromyalgia pain. FMS patients and healthy controls (n=22 each, age- and gender-matched) were recruited. The surface area over the upper trapezius muscle on each side was divided into 13 sub-areas (points) of 1cm in diameter for each point. Pressure pain threshold (PPT) and the local and referred pain pattern induced by manual palpation at 13 points bilaterally in the upper trapezius were recorded. Results showed that PPT levels at all measured points were significantly lower in FMS than controls. Multiple active MTrPs (7.4+/-2.2) were identified bilaterally in the muscle in FMS patients, but no active MTrPs were found in controls. The mid-fiber region of the muscle had the lowest PPT level with the largest number of active MTrPs in FMS and with the largest number of latent MTrPs in controls. The local and referred pain pattern induced from active MTrPs bilaterally in the upper trapezius muscle were similar to the ongoing pain pattern in the neck and shoulder region in FMS. In conclusion, active MTrPs bilaterally in the upper trapezius muscle contribute to the neck and shoulder pain in FMS. Active MTrPs may serve as one of the sources of noxious input leading to the sensitization of spinal and supraspinal pain pathways in FMS.
Article
The aim of this study was to investigate whether generalized deep tissue hyperalgesia exists in patients with chronic unilateral lateral epicondylalgia (LE). A total of 26 LE patients (10 males and 16 females, aged 25 to 63 y) and 20 healthy comparable matched controls (aged 26 to 61 y) were recruited and pressure pain threshold (PPT) was assessed bilaterally over the median, ulnar, and radial nerve trunks, the lateral epicondyle, C5-C6 zygapophyseal joint, and the tibialis anterior muscle in a blind design. PPT was significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the lateral epicondyle, the C5-C6 zygapophyseal joint, and tibialis anterior muscle in patients with LE than healthy controls (all P<0.001). PPTs over those measured points was negatively related to current elbow pain intensity (all P<0.05). A more significant decrease in PPTs were present in females (all P<0.05). This revealed a widespread mechanical hypersensitivity in patients with LE, which suggest that central sensitization mechanisms are involved in patients with unilateral LE. The generalized decrease in PPT levels was associated with elbow pain intensity, supporting a role of peripheral sensitization mechanisms in the initiation or maintenance of central sensitization mechanisms. In addition, females may be more prone to the development of generalized mechanical hypersensitivity.