ArticleLiterature Review

Myofascial pain syndromes and their evaluation

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Abstract

This article reviews the available published knowledge about the diagnosis, pathophysiology and treatment of myofascial pain syndromes from trigger points. Furthermore, epidemiologic data and clinical characteristics of these syndromes are described, including a detailed account of sensory changes that occur at both painful and nonpainful sites and their utility for diagnosis and differential diagnosis; the identification/diagnostic criteria available so far are critically reviewed. The key role played by myofascial trigger points as activating factors of pain symptoms in other algogenic conditions--headache, fibromyalgia and visceral disease--is also addressed. Current hypotheses on the pathophysiology of myofascial pain syndromes are presented, including mechanisms of formation and persistence of primary and secondary trigger points as well as mechanisms beyond referred pain and hyperalgesia from trigger points. Conventional and most recent therapeutic options for these syndromes are described, and their validity is discussed on the basis of results from clinical controlled studies.

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... Since most TrPs are formed as a consequence of traumatic/microtraumas to muscle structures (primary trigger points), collection of the clinical history should specifically include questions aimed at ascertaining the occurrence of events and/or activities which could have promoted such events, including direct traumas, overuse or misuse of specific muscles, their repeated overload in relation to particular habits/activities/sports (Alvarez and Rockwell 2002;Money 2017;Parthasarathy et al. 2019;Saggini et al. 2007). However, trigger point formation can also be secondary to visceral painful events, in this case TrPs occur in muscle structures located in the referred pain area from a specific viscus as a consequence of the "parietalization" process of visceral pain, especially when the visceral algogenic process has been particularly prolonged or intense or repetitive (e.g., as in the case of colics) (Giamberardino et al. 2011b). Thus collection of the clinical history should include questions directed at ascertaining the previous occurrence of visceral pain episodes/diseases with projection to the muscles suspected to harbor the TrPs. ...
... If so, as in the case, for instance, of the sternocleidomastoid, pincer palpation is applied, i.e., the muscle fibers are grasped and pressed together between the thumb and index finger. If the muscle can be approached in only one direction snapping palpation is applied, i.e., the fingertip is placed at a right angle to the direction of muscle fibers and then suddenly pressed down while drawing the finger back, so as to roll the fibers themselves under the finger (Giamberardino et al. 2011b). With both monoeuvers, the so-called "local twitch response" of muscle fibers (LTR) can be elicited. ...
... This produces a continued contracture of sarcomeres, which in turn perpetuates hypoxia, leading to a vicious circle of automaintenance (Kuan 2009). The most effective therapy of TrPs is, indeed, local deactivation of the vicious circle of contracture-hypoxia-contracture through mechanical disruption via needle penetration (dry needling) or injection with local anesthetic (to alleviate the local discomfort but without provoking any muscle damage), but techniques of TrP release such as the ischemic compression procedure or desensitization of parietal tissues overlying the TrPs using NSAID or lidocaine plasters are also effective measures (Affaitati et al. 2009(Affaitati et al. , 2018aGiamberardino et al. 1996Giamberardino et al. , 2011bScott et al. 2009). ...
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Many pain conditions in patients tend to co-occur, influencing the clinical expressions of each other in various ways. This paper summarizes the main concurrent pain conditions by analyzing the major interactions observed. In particular, co-occurrence will be examined in: visceral pain (especially ischemic heart disease, irritable bowel syndrome, dysmenorrhea/endometriosis and urinary pain), fibromyalgia, musculoskeletal pain and headache. Two concurrent visceral pains from internal organs sharing at least part of their central sensory projection can give rise to viscero-visceral hyperalgesia, i.e., enhancement of typical pain symptoms from both districts. Visceral pain, headache and musculoskeletal pains (myofascial pain from trigger points, joint pain) can enhance pain and hyperalgesia from fibromyalgia. Myofascial pain from trigger points can perpetuate pain symptoms from visceral pain conditions and trigger migraine attacks when located in the referred pain area from an internal organ or in cervico-facial areas, respectively. The pathophysiology of these pain associations is complex and probably multifactorial; among the possible processes underlying the mutual influence of symptoms recorded in the associations is modulation of central sensitization phenomena by nociceptive inputs from one or the other condition. A strong message in these pain syndrome co-occurrence is that effective treatment of one of the conditions can also improve symptoms from the other, thus suggesting a systematic and thorough evaluation of the pain patient for a global effective management of his/her suffering.
... Myofascial Pain Syndrome (MPS) is a regional pain disorder that affects every age-group and is characterized by the presence of trigger points (TrPs) within muscles or fascia [1,2]. Commonly recognized as "muscle knots," MPS is the most common cause of persistent regional pain [1e4]. ...
... Commonly recognized as "muscle knots," MPS is the most common cause of persistent regional pain [1e4]. Simon's original definition of MPS remains the best; he defined it as a "complex of sensory, motor, and autonomic symptoms that are caused by myofascial trigger points" [1]. TrPs are defined as tender or hyperirritable areas in muscles and/or their fascia that are localized in taut, palpable bands, which mediate a local twitch response (a small, quick contraction of muscle fibers that occurs with radiation of pain) under snapping palpation [1,5]. ...
... Simon's original definition of MPS remains the best; he defined it as a "complex of sensory, motor, and autonomic symptoms that are caused by myofascial trigger points" [1]. TrPs are defined as tender or hyperirritable areas in muscles and/or their fascia that are localized in taut, palpable bands, which mediate a local twitch response (a small, quick contraction of muscle fibers that occurs with radiation of pain) under snapping palpation [1,5]. (see Tables 1e5) MPS symptoms may occur after muscle overuse or injury, but there are some patients with no precipitating factors [6]. ...
Myofascial Pain Syndrome (MPS) is a regional pain disorder that affects every age group and is characterized by the presence of trigger points (TrPs) within muscles or fascia. MPS is typically diagnosed via physical exam, and the general agreement for diagnostic criteria includes the presence of TrPs, pain upon palpation, a referred pain pattern, and a local twitch response. The prevalence of MPS among patients presenting to medical clinics due to pain ranges anywhere from 30-93%. This may be due to the lack of clear criteria and guidelines in diagnosing MPS. Despite the prevalence of MPS, the pathophysiology of it remains incompletely understood. There are many different ways to manage and treat MPS. Some include exercise, TrP injections, medications, and other alternative therapies. There needs to be more research done to form uniformly accepted diagnostic criteria and treatments.
... Hypoperfusion/ischaemia due to ex cessive muscle contraction lead to increased mediators and acidification triggering a vicious cycle. This vicious cycle causes excessive stimulation of nociceptors and hence pain [1,3,5]. The main objective of treatment is breaking this cycle. ...
... The prevalence of MPS, which is one of the most important causes of functional impairment in daily life, is not exactly known due to the absence of generally accepted diagnostic criteria [1,2]. MPS is most ly seen in the neckshoulder region, and the most com monly involved muscle is the upper part of the trapezius [2,3]. Although the aetiology is not known, factors such as muscle injuries overuse of muscles, repetitive move ments, poor working conditions, inactivity, anxiety, and depression may cause development of myofascial pain or aggravation of the clinical picture [2,3,12]. ...
... MPS is most ly seen in the neckshoulder region, and the most com monly involved muscle is the upper part of the trapezius [2,3]. Although the aetiology is not known, factors such as muscle injuries overuse of muscles, repetitive move ments, poor working conditions, inactivity, anxiety, and depression may cause development of myofascial pain or aggravation of the clinical picture [2,3,12]. The diagnosis of MPS is difficult because of the lack of generally accepted diagnostic criteria. ...
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Purpose: The aim of the study was to investigate the contribution of shear wave elastography to the diagnosis of myofascial pain syndrome (MPS) of the upper part of the trapezius. Material and methods: Ethical committee approval was obtained for the study. Thirty volunteer women with trigger points in the upper part of the trapezius muscle and 30 healthy women with a similar age distribution were included in the study. The patient group performed a self-stretching exercise program for 4 weeks. No intervention was applied to the control group. Muscle stiffness values of both groups were evaluated with shear wave elastography (SWE), and pain levels of all volunteers were evaluated by the Visual Analogue Scale at the beginning and the end of the study. The statistical analyses were performed using SPSS version 18.0. Results: There was a significant decrease after the treatment in terms of upper trapezius muscle stiffness and the pain levels in the patient group (p < 0.001 and p < 0.001). In the patient group, there was a moderate correlation between the decrease in the pain level and the reductions in muscle stiffness (r = 0.595). In control group, there was no significant difference in terms of both muscle stiffness and pain levels before and after treatment (p > 0.05). Conclusions: SWE is a reliable method for detecting latent trigger points in MPS, and it can be used for evaluating the response to treatment. Key words: myofascial pain syndrome, latent trigger point, shear wave elastography.
... Myofascial pain denotes a pain arising from muscle and fascia. Commonly known as "muscle knots" myofascial pain usually arises in 'trigger points' (TrPs) or 'tender spots' [2][3][4]. TrPs are small and sensitive areas in a contracted muscle, that spontaneously or upon compression cause pain to a distant region, known as a referred pain zone [3,4]. Traditionally, "TrPs" are perceived as associated with MPS and differ from "tender points" mainly in that they radiate pain [2][3][4]. ...
... Commonly known as "muscle knots" myofascial pain usually arises in 'trigger points' (TrPs) or 'tender spots' [2][3][4]. TrPs are small and sensitive areas in a contracted muscle, that spontaneously or upon compression cause pain to a distant region, known as a referred pain zone [3,4]. Traditionally, "TrPs" are perceived as associated with MPS and differ from "tender points" mainly in that they radiate pain [2][3][4]. ...
... TrPs are small and sensitive areas in a contracted muscle, that spontaneously or upon compression cause pain to a distant region, known as a referred pain zone [3,4]. Traditionally, "TrPs" are perceived as associated with MPS and differ from "tender points" mainly in that they radiate pain [2][3][4]. ...
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Background Myofascial Pain Syndrome (MPS) is a common, overlooked, and underdiagnosed condition and has significant burden. MPS is often dismissed by clinicians while patients remain in pain for years. MPS can evolve into fibromyalgia, however, effective treatments for both are lacking due to absence of a clear mechanism. Many studies focus on central sensitization. Therefore, the purpose of this scoping review is to systematically search cross-disciplinary empirical studies of MPS, focusing on mechanical aspects, and suggest an organic mechanism explaining how it might evolve into fibromyalgia. Hopefully, it will advance our understanding of this disease. Methods Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and abstract, then full text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. PROSPERO yet to adapt registration for scoping reviews. Findings 799 records included. Fascia can adapt to various states by reversibly changing biomechanical and physical properties. Trigger points, tension, and pain are a hallmark of MPS. Myofibroblasts play a role in sustained myofascial tension. Tension can propagate in fascia, possibly supporting a tensegrity framework. Movement and mechanical interventions treat and prevent MPS, while living sedentarily predisposes to MPS and recurrence. Conclusions MPS can be seen as a pathological state of imbalance in a natural process; manifesting from the inherent properties of the fascia, triggered by a disrupted biomechanical interplay. MPS might evolve into fibromyalgia through deranged myofibroblasts in connective tissue (“fascial armoring”). Movement is an underemployed requisite in modern lifestyle. Lifestyle is linked to pain and suffering. The mechanism of needling is suggested to be more mechanical than currently thought. A “global percutaneous needle fasciotomy” that respects tensegrity principles may treat MPS/fibromyalgia more effectively. “Functional-somatic syndromes” can be seen as one entity (myofibroblast-generated-tensegrity-tension), sharing a common rheuma-psycho-neurological mechanism.
... In each of the 40 participants, a physician examined the trapezius muscles of the neck and upper back to identify any myofascial trigger points (MTrPs). As there is still no consensus in the diagnostic criteria of myofascial pain syndrome [13,14], the diagnosis was made by MTrP identification through comprehensive physical examination. Doctors diagnosed nine baseball players with myofascial pain syndrome. ...
... This study had several limitations. First, there is no universally accepted criteria for the diagnosis of myofascial pain syndrome [13,14]. Hence, we defined the condition only through the existence of MTrP based on the physical examination in our study. ...
Article
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Purpose This study aimed to develop a quantitative dry cupping system that can monitor negative pressure attenuation and soft tissue pull-up during cupping to quantify soft tissue compliance. Methods Baseball players with myofascial pain syndrome were recruited to validate the benefits of cupping therapy. Nine of 40 baseball players on the same team were diagnosed with trapezius myofascial pain syndrome; another nine players from the same team were recruited as controls. All participants received cupping with a negative pressure of 400 mmHg for 15 minutes each time, twice a week, for 4 weeks. Subjective perception was investigated using upper extremity function questionnaires, and soft tissue compliance was quantified objectively by the system. Results During the 15-minute cupping procedure, pressure attenuation in the normal group was significantly greater than that in the myofascial group ( p = 0.017). The soft tissue compliance in the normal group was significantly higher than that in the myofascial group ( p = 0.050). Moreover, a 4-week cupping intervention resulted in an obvious increase in soft tissue lift in the myofascial pain group ( p = 0.027), although there was no statistical difference in the improvement of soft tissue compliance. Shoulder ( p = 0.023) and upper extremity function ( p = 0.008) were significantly improved in both groups, but there was no significant difference between the two groups. Conclusion This quantitative cupping monitoring system could immediately assess tissue compliance and facilitate the improvement of soft tissues after cupping therapy. Hence, it can be used in athletes to improve their functional recovery and maintain soft tissues health during the off-season period.
... (13) Los puntos gatillo son nódulos hiperirritables dentro de una fibra/banda tensa dentro de un músculo esquelético y esta fibra se encuentra acortada de manera permanente, lo que genera disfunciones mecánicas del músculo y dolor. (14)(15)(16)(17)(18)(19)(20)(21)(22) Lo encontramos representado en un esquema en la figura 1. (23) Para el diagnóstico de estos puntos es necesario realizar una palpación concreta dentro del músculo de una banda tensa y el nódulo, (14,16,18,24) que es especialmente sensible a la presión. Si el PG está activo, la palpación del nódulo dará lugar a un dolor referido hacia otras zonas alejadas del punto que el paciente describe como el dolor que padece. ...
... ü Nódulo palpable y que al presionarlo genere dolor referido que el paciente identifique como su dolor. (14,16,18,24) o En relación a la edad: será necesario para participar en el estudio que los pacientes tengan 18 años (mayoría de edad) en adelante. ...
Experiment Findings
Background and objectives: Shoulder pain in patients with spinal cord injury is one of the most prevalent pathologies, especially due to the use of assistive devices, since the joint is initially prepared for other functions. It is a hypermobile joint with little stability, so it is often 1 injured. The aim of this study is to prove if dry needling used in these patients is effective in the disability (DASH) of the sample. Methods: In this randomized, single-blind, controlled trial, it was used the fast-in and fast-out Hong technique on an active trigger point in infraspinatus muscle within the experimental group and compared with a control group that received a treatment of placebo needle. The variables used in this study are: DASHe (Disabilities of the Arm, Shoulder and Hand version Spanish version), McGill pain questionnaire, SPADIe (Shoulder Pain and Disability Index Spanish version) that were evaluated before and one week after the intervention, and pain pressure threshold (PPT) and range of motion (ROM) of the shoulder of internal rotation and horizontal adduction that were evaluated before, immediately after and a week after the intervention.
... Minor requirements include the following: (i) Pressure on the TrP reproduces spontaneously felt pain and changes in sensations; (ii) Elicitation of an LTR of muscle fibers by transverse 'snapping' palpation or by needle insertion into the TrPs; and (iii) muscle stretching or a TrP injection can help to ease discomfort. [37] There were several variations across the investigations, including participants, examiners, settings, muscles, and diagnostic technique variances. Two systematic reviews, in particular, have been done with the goal of assessing the reliability of physical examination in detecting an MTrP. ...
... The ultrasound approach might be especially useful in the treatment of TrPs in deeper muscles that are difficult to reach with manual therapy. [37] According to Saxena et al. in their published article mention some non-invasive, nonmanual therapies, that is, TENS, EMS, HVGS, IFC, and FREMS. They stated that the lesser treatment has strong evidence to relief of acute and chronic MPS and moderate effect has been observe by the use of TENS, magnet, and acupuncture. ...
Article
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This paper synthesized the available published literature on myofascia, its structure, myofascial disorder, causative factors, scientific methods for evaluation and treatments, etc. The importance of myofascial in chronic and acute musculoskeletal pain is overlooked. According to Waller et al., mention in their article, up to 85% of people will experience myofascial pain at least once during their life. The myofascia is a musculoskeletal cell matrix that supports muscular connective tissue, it is essential for generating forces between muscles and also provides better flexibility. Myofascial pain syndrome is described as sensory, motor, and autonomic signs and symptoms that are produced by trigger points or taut bands of skeletal muscle or fascia. A myofascial trigger point is painful on compression and can give rise to referred pain, motor dysfunction, and automatic event, it restricts the range of motion and force generation capacity. Therefore, it is utmost importance to know about myofascial disorders, their prevention techniques, diagnosis, and treatment.
... Distinction between trigger point types is possible when performing various diagnostic procedures. In these types of cases, anamnesis and provocation tests may be useful in a clinical examination (14). It is believed that in the area of the shoulder girdle, TrPs most often occur on the upper trapezius muscle and may be closely related to various myofascial ailments of this area of the body (14). ...
... In these types of cases, anamnesis and provocation tests may be useful in a clinical examination (14). It is believed that in the area of the shoulder girdle, TrPs most often occur on the upper trapezius muscle and may be closely related to various myofascial ailments of this area of the body (14). The main objective of this study was to evaluate the effectiveness of a therapy that is a combination of Muscle Energy Technique (MET) and TPT, performed bilaterally on the upper trapezius muscle in a group of asymptomatic persons with latent TrPs. ...
Article
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(1) Background: The aim of the study was to determine the effect of the combination therapy of Muscle Energy Technique (MET) and Trigger Point Therapy (TPT) on the angular values of the range of movements of the cervical spine and on the pressure pain threshold (PPT) of the trapezius muscle in asymptomatic individuals. METHODS: The study involved 60 right-handed, asymptomatic students with a latent trigger point in the upper trapezius muscle. All qualified volunteers practiced amateur symmetrical sports. The study used a tensometric electrogoniometer (cervical spine movement values) and an algometer (pressure pain threshold (PPT) of upper trapezius). Randomly (sampling frame), volunteers were assigned to three different research groups (MET + TPT, MET and TPT). All participants received only one therapeutic intervention. Measurements were taken in three time-intervals (pre, post and follow-up the next day after therapy). (2) Results: One-time combined therapy (MET + TPT) significantly increases the range of motion occurring in all planes of the cervical spine. One-time treatments of single MET and single TPT therapy selectively affect the mobility of the cervical spine. The value of the PPT significantly increased immediately after all therapies, but only on the right trapezius muscle, while on the left side only after the therapy combining MET with TPT. (3) Conclusion: The MET + TPT method proved to be the most effective, as it caused changes in all examined goniometric and subjective parameters.
... This cross-sectional study included 25 patients with unilateral chronic trapezius MPS fulfilling the criteria for the diagnosis of MPS according to Travell and Simons criteria. It required the presence of five major and one minor criteria [16]. The major criteria include (i) the presence of regional pain complaint, (ii) the pain pattern follows a known distribution of muscular referred pain, (iii) the presence of palpable taut band, (iv) the presence of focal tenderness at one point or nodule within the taut band, and (v) the presence of a degree of restricted range of motion. ...
... The major criteria include (i) the presence of regional pain complaint, (ii) the pain pattern follows a known distribution of muscular referred pain, (iii) the presence of palpable taut band, (iv) the presence of focal tenderness at one point or nodule within the taut band, and (v) the presence of a degree of restricted range of motion. The minor criteria include (i) manual pressure on the MTrP nodule reproduce chief pain complaint, (ii) snapping palpation of the taut band at the MTrP elicits a local muscle twitch response, and (iii) the pain is decreased or eliminated by muscular treatment (muscle stretching or injection of the MTrP) [16]. The patients were enrolled randomly from those attending the outpatient clinic of Physical Medicine, Rheumatology and Rehabilitation Department, Main University Hospital, Alexandria Faculty of Medicine. ...
Article
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Background Myofascial pain syndrome is a common musculoskeletal problem affecting the trapezius muscle. The aim was to assess the presence of spinal accessory neuropathy in patients with unilateral chronic trapezius myofascial pain syndrome. Results The study included 25 patients with unilateral chronic trapezius myofascial pain syndrome and 20 apparently healthy volunteers as the control group. There was a significantly delayed spinal accessory nerve latency on the symptomatic side in comparison to either asymptomatic side ( P = 0.014) and control group ( P = 0.001). Compound muscle action potential amplitude did not significantly differ between the symptomatic side versus the asymptomatic side and control group. Delayed spinal accessory nerve latency was present in seven patients (28%) and reduced compound muscle action potential amplitude in one of them (4%). The needle electromyography of the upper trapezius muscle revealed neuropathic motor units and incomplete interference pattern in the patient who showed reduced compound muscle action potential amplitude. Abnormal rest potentials were absent in all patients. Individually, seven patients (28%) had electrophysiological evidence of spinal accessory neuropathy, but only one (4%) of them had clinical evidence of spinal accessory neuropathy. Patients with abnormal electrophysiological findings had longer duration of complaint and more severe pain. Conclusions Spinal accessory neuropathy is common among patients with chronic trapezius myofascial pain syndrome. It could contribute to increased pain severity of myofascial pain syndrome. Electrodiagnosis is a good modality for identifying subclinical spinal accessory neuropathy.
... The pain evaluation in MPS was employed using PPT. The trigger point regions, whether active or latent, present a lower PPT than normal muscle [41,45]. Therefore, PPT is commonly employed to reflect the degree of muscle tolerance to pain of the subject [46]. ...
... Central sensitization has become prominent or independent for sustained pain in MPS, therefore pain may persist long although the local trigger point has been dissolved [55]. Referred pain should be considered as a central phenomenon and result of central sensitization [52] or central hyperexcitability [45]. ...
Article
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Background: Myofascial pain syndrome (MPS) is a condition with local and referred pain characterized by trigger points (taut bands within the muscle). Ischemic compression is a noninvasive manual therapy technique that has been employed for the treatment of MPS in past decades. However, little attention has been devoted to this topic. Objectives: The present review was designed to explore the efficacy of ischemic compression for myofascial pain syndrome by performing a descriptive systematic review and a meta-analysis to estimate the effect of ischemic compression on MPS. Methods: A systematic review and meta-analysis concerning randomized controlled trials (RCTs) with myofascial pain subjects who received ischemic compression versus placebo, sham, or usual interventions. Five databases (PubMed, The Cochrane Library, Embase, Web of Science, Ovid) were searched from the earliest data available to 2022.1.2. The standardized mean difference (SMD) and the 95% confidence interval (CI) were used for statistics. Version 2 of the Cochrane risk of tool 2 (RoB 2) was used to assess the quality of the included RCTs. Results: Seventeen studies were included in the systematic review, and 15 studies were included in the meta-analysis. For the pressure pain threshold (PPT) index, 11 studies and 427 subjects demonstrated statistically significant differences compared with the control at posttreatment (SMD = 0.67, 95% CI [0.35, 0.98], P < 0.0001, I2 = 59%). For visual analog scale (VAS) or numeric rating scale (NRS) indices, 7 studies and 251 subjects demonstrated that there was no significant difference between ischemic compression and controls posttreatment (SMD = - 0.22, 95% CI [- 0.53, 0.09], P = 0.16, I2 = 33%). Conclusion: Ischemic compression, as a conservative and noninvasive therapy, only enhanced tolerance to pain in MPS subjects compared with inactive control. Furthermore, there was no evidence of benefit for self-reported pain. The number of currently included subjects was relatively small, so the conclusion may be changed by future studies. Big scale RCTs with more subjects will be critical in future.
... Its effectiveness has been demonstrated in several previous studies. [4][5][6] However, it can induce complications, such as bleeding, muscle hematoma, vasovagal syncope, skin infections, and pneumothorax. [7][8][9] This report describes a patient with TPIinduced iatrogenic spinal cord injury (SCI). ...
Article
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Trigger point injection (TPI) is commonly administered for myofascial pain syndrome management, but occasionally leads to complications, including bleeding, muscle hematoma, vasovagal syncope, skin infections, and pneumothorax. This report presents a case of TPI-induced iatrogenic spinal cord injury (SCI). A 59-year-old woman received TPI for myofascial pain on both thoracolumbar paraspinal muscles. She experienced an electric shock sensation throughout the lower extremities upon receiving blind TPI in the left thoracolumbar paraspinal muscle, and later complained of weakness (manual muscle test grade: 0-2) and neuropathic pain (numeric rating scale [NRS]: 7) in the lower left extremity. Thoracolumbar magnetic resonance imaging (MRI) 3 days after the TPI revealed a high-intensity T2 signal in the left T12 to L2 spinal cord segments, indicating the presence of edema or inflammation in this region. In concordance with the MRI findings, electrophysiological recordings performed 11 days after the TPI revealed no central motor conduction time response in the left leg. At 7 months post-onset, the patient had partially recovered motor function and neuropathic pain was reduced to NRS 4. Clinicians should be aware of the possibility of needle-induced SCI during paraspinal muscle TPI; imaging guidance may be helpful for accurate needle targeting during the procedure.
... [15] The age group showing the highest incidence was the 20-40 year age group, although children can also have MPD syndrome. [16] The average age of women suffering from osteopenia and osteoporosis was 59.2±10.5 years in a study. [17] Females were more commonly affected than males in our study. ...
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The aim of the present study was to evaluate the effectiveness of oral nano formulation of vitamin-D in pain management of some neurospinal and musculoskeletal disorders. The study was conducted for duration of two years on patients suffering from neurospinal disorders like generalised back pain, myofascial syndrome, osteopenia and osteoporosis. Numerical Rating scale was used to assess pain scores before and after treatment. The dose of vitamin-D formulation was 60,000IU weekly for six weeks. Non-parametric tests were employed for qualitative data and quantitative data (with non-Gaussian distribution) to find out statistically significant relation between the variables. Vitamin-D levels and pain scores within the group were compared using Wilcoxon test. p-value<0.05 was considered as statistically significant. p-value<0.01 was considered as statistically highly significant. There was a very highly statistically significant association between vitamin-D formulation and improvement in vitamin-D levels (p<0.0001) and pain scores (p<0.0001). Our study concludes that oral nano formulation of vitamin-D if given at 60,000 IU weekly for six weeks was effective in treating pain due to some musculoskeletal and neurospinal disorders.
... Cranial examination should include: inspection for exophthalmia or swelling of the eyelids; redness of the eyes; palpation of the eyeballs, temporal arteries and cranial sinuses; nuchal rigidity; focal lesions or rashes; and, auscultation of the vessels for cervical or cranial murmurs [17,18]. Palpation of the cervical muscles, which are very often contracted and painful in the case of a tension-type headache, can identify the presence of myofascial trigger points. ...
Article
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Introduction Headache is the fifth most common reason to visit an emergency department (ED). In most of the cases headache is benign and has a primary origin, with migraine as the most common diagnosis. Inappropriate use of ED for non-emergency conditions causes overcrowding, unnecessary testing and increased medical costs. Areas covered All stages of headache management in ED, from the reasons to go there, the diagnosis that is made and the investigations necessary to make it, to get to the therapies administered and those prescribed at discharge, if there were any. Finally, the authors evaluated the habit of recommending medical follow-up and how often the headache is still present at discharge or returns within 24 hours. Expert Opinion Primary headaches are underdiagnosed, misdiagnosed and the majority do not receive drug therapy either in ED or on discharge, and in cases where the therapy is prescribed is not specific. Increase the number of primary care medical services, spread the “headaches culture” among GPs and ED doctors, the adoption of ICHD in the diagnostic protocols used in EDs and a fast referral to a headache center could decrease the inappropriate use of ED and improve the headache management in the emergency units.
... Approximately 30 to 85% of patients who visit healthcare professionals for musculoskeletal complaint are usually reported to have MPS. [2,3] The most common etiologies of myofascial pain and dysfunction include direct or indirect traumas, vertebral pathologies, exposure to cumulative and repetitive strain, postural dysfunction, and physical incapacity. Medical history and physical examination are diagnostic in MPS. ...
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Objectives: In this study, we aimed to investigate whether there was any difference in kinesiotaping (KT) application on the upper trapezius muscle between a trained and untrained physiatrist in the management of patients with myofascial pain syndrome (MPS). Patients and methods: Between April 2013 and July 2015, a total of 45 patients (44 females, 1 males; mean age 31.9±8.0 years; range, 18 to 55 years) with MPS were included in this prospective, single-blind, randomized-controlled study. The patients were randomly divided into two groups. The first group (intervention group, n=24) was administered KT band with the muscle in a tense condition according to the muscle technique performed by a trained physiatrist, from the muscle origo toward its insertion point. The second group (control group, n=21) received no technique and KT was applied to the painful area by an untrained physiatrist using a randomly selected method. Primary outcome measures were pain at rest, during activity (0-10 cm visual analog scale), and threshold measurement with algometry (kg/cm2). Secondary outcome measures were function (Neck Pain and Disability Scale), degree of palpable muscle spasm, and quality of life (Nottingham Health Profile). All evaluations were performed at baseline, at three and six weeks after the treatment. Results: There were significant improvements in all parameters in both groups. There were no significant differences in any parameters at six weeks. We demonstrated that KT, which was applied on active trigger points on the upper trapezius muscle by trained and untrained physiatrists, improved pain, palpable muscle spasm, neck function, quality of life, and patient satisfaction degree in patients with MPS. Conclusion: Our study results show that KT, which is applied by trained and untrained physiatrists, improves pain, palpable muscle spasm, neck function, quality of life in patients with MPS.
... C hronic myofascial pain syndrome (CMPS) is a syndrome of musculoskeletal pain that is typically linked to myofascial trigger points (MTrP) (1,2). CMPS is mostly prevalent in muscles that are consistently active against gravity or muscles that are essential in repetitive activities, such as the head, neck, shoulders, hips and low back muscles (3). The postural muscles that most commonly tend to be shortened are the upper trapezius and levator scapulae, resulting in limited neck mobility (4) and, due to the continuous demand on these muscles to maintain an upright posture, there appears to be a strong justification for stretching them. ...
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Objective: To explore the effect of variable durations of stretching on neural function, pain, and algometric pressure in patients with chronic myofascial pain syndrome. Design: Randomized controlled trial. Patients: A total of 100 participants diagnosed with chronic myofascial pain syndrome were randomly assigned to a control group or 1 of 3 intervention groups. Methods: The 3 experimental groups received different durations of cervical spine stretching: 15, 30 or 60 s. The control group did not stretch. Primary outcome measures included peak-to-peak somatosensory-evoked potential for dermatomes C6, C7 and C8. Secondary outcome measures included central somatosensory conduction time (N13-N20), pain intensity, and pressure-pain threshold algometric measurements. All outcome measures were assessed immediately after and 2 h after the treatment session. Results: Post hoc analysis indicated that stretching for 60 s significantly decreased the dermatomal amplitude for C6, C7 and C8 (p < 0.001) and significantly increased the central conduction time, indicating negative effect (p < 0.001). Stretching for 30 and 60 s resulted in greater improvement in pain intensity and algometric pressure than stretching for 15 s or no stretch (control) < 0.001. Conclusion: Stretching cervical muscles involved in chronic myofascial pain syndrome for 30 s was optimal in achieving stretching benefits and minimizing the negative effects on the neural function of the involved nerve roots and central nervous system.
... A statistically as well as clinically significant difference was observed with a decrease in the active MTrPs of shoulder muscles in the intervention group compared to the control group. This result reinforces the presupposed biomedical mechanisms underlying MTrPs therapy 37) . More recently, Ganesh et al. 38) showed a significant increase in CROM and decrease in pressure pain sensitivity after cervical mobilization and ischemic compression therapy in patients with latent trigger points 38) . ...
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[Purpose] To investigate the effect of pulsed Nd:YAG laser combined with the progressive pressure release technique (PPRT) and exercises in the treatment of myofascial trigger points (MTrPs) in patients with myofascial pain syndrome (MPS). [Participants and Methods] A total of 50 patients with MTrPs in the upper trapezius muscle participated in the study. The patients were randomly assigned to two groups and treated with laser plus PPRT (Laser + PPRT group) or placebo laser and exercises (PL + PPRT group). The laser was applied for eight MTrPs with a 50 J/point. PPRT was applied for 30 seconds for each point. Exercises included strengthening and stretching exercises applied three times per week for four weeks. A visual analogue scale (VAS) and pressure pain threshold (PPT) were used to measure pain and pain threshold, respectively. A cervical range of motion device (CROM) was used to measure the cervical range of motion. [Results] Both treatment groups showed significant improvement in CROM, PPT, and VAS post-treatment with a more significant effect in the Laser + PPRT group compared to the PL + PPRT group. [Conclusion] PPRT and exercises alone or that in combination with laser therapy were effective in the treatment of active MTrPs in patients with MPS.
... The main goal of the MPS treatment is to decrease the pain and regional muscle spasm by inactivating trigger points. [16] In the literature, there are several randomized clinical studies and systematic reviews regarding the effectiveness of DN on MPS; [17][18][19][20][21][22][23][24][25] however, the number of studies on KT is limited. [8][9][10][26][27][28] In addition, there is no head-to-head study comparing DN and KT in MPS treatment. ...
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Objectives: This study aims to compare the effectiveness of dry needling (DN) and kinesiotaping (KT) therapies on pain, quality of life, depression, and physical function in the treatment of myofascial pain syndrome (MPS). Patients and methods: The study included a total of 60 patients (4 males, 56 females; mean age 31.2±9.8 years; range, 18 to 56 years) diagnosed with MPS between January 2014 and June 2014. The patients were randomly divided into two treatment groups: the DN group (n=30) and KT group (n=30). Both groups performed stretching and postural exercises. The scales used for measurements were the Visual Analog Scale (VAS) for pain, a pressure algometer for the pressure-pain threshold, the Short Form-36 (SF-36) for the quality of life, Beck Depression Inventory (BDI) for depression, and the Neck Pain and Disability Scale (NPDS) for physical function. The patients were evaluated by a single assessor three times: pre-treatment, at the end of the treatment, and two months after the treatment. Results: Both DN and KT provided significant improvements for all baseline measurements (VAS, pressure pain threshold, all subscales of SF-36, BDI, and NPDS scores) at the end of the treatment and two months after the treatment (p<0.05). However, there was no significant difference between the groups in all measurements (p>0.05). Conclusion: Kinesiotaping is as an effective method as DN in the treatment of MPS. It can be served as a non-invasive alternative to patients with needle phobia.
... Myofascial pain syndrome is a clinical condition characterized by the presence of local muscle pain, symptomatic myofascial trigger points, and changes in the sensory, motor, and autonomic systems. 1,2 It is estimated that it is a primary cause of pain in 53% to 85% of admissions in pain treatment centers and in 46% of the general population, [3][4][5] affecting the lives of individuals who begin experiencing functional deficits, humor changes, and decreases in quality of life. 6,7 Repetitive use, overload, and direct trauma to the muscle are known as the main causes of onset of a myofascial trigger point (MTp). ...
Article
Objective The purpose of this study was to assess whether dry needling (DN) added to photobiomodulation (PBM) has effects on the treatment of active myofascial trigger points in the upper trapezius. Methods This study was a randomized clinical trial, with 43 participants divided into 3 groups: DN and PBM (DNP), DN, and DN outside of the trigger point (DNout). Each group received 1 session of DN followed by PBM therapy with the machine turned on or off. Pain, disability, pain pressure threshold, and muscle activity were assessed before the intervention and afterward at intervals of 10 minutes, 30 minutes, 1 week, and 1 month. Results Pain decreased after intervention in the DNP and DNout groups, with mean differences, respectively, of 1.33 cm (95% confidence interval [CI], 0.019-2.647) and 2.78 cm (95% CI, 1.170-2.973). Scores for the disability questionnaire decreased in all groups after intervention (F = 36.53, P < .0001) after the intervention, with mean differences of 3.8 points in the DNP group (95% CI, 1.082-5.518), 3.57 in the DN group (95% CI, 0.994-6.149), and 5.43 in the DNout group (95% CI, 3.101-7.756). There were no significant differences between or within groups in pain pressure threshold (F = 2.14, P = .139), with mean differences after 30 minutes of 0.139 kgf for the DNP group (95% CI, −0.343 to 0.622), 0.273 for the DN group (95% CI, −0.661 to 1.209), and −0.07 for the DNout group (95% CI, −0.465 to 0.324). Muscle activation for the DN group increased 8.49% after the intervention, where for the DNP group it decreased 11.5%, with a significant difference between groups. Conclusion DN added to PBM presented similar results compared to DNout and DN. In this sample, the effects of the application of DN outside of the trigger point had better effects on pain and disability scores than DN applied directly on the trigger point.
... Chronic pain represents a major health problem in adolescent and adult populations 1) , affecting 30-50% of people worldwide 2) . Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder in which pain occurs due to a palpable spot in a taut band of muscle known as a trigger point 3) . MPS usually presents with deep, aching, and referred pain along the dermatome of innervating nerves in the muscle containing the trigger point. ...
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[Purpose] In the present study, electroencephalography was used to explore neural activity related to electromyography biofeedback training, focusing on pain perception before and after electromyography biofeedback. [Participants and Methods] Twenty-seven participants (female=23; mean age: 28.85 ± 4.99 years) with mild-to-moderate myofascial pain syndrome in the upper trapezius were recruited for this study. All participants underwent electroencephalography recording before, during, and after (0 and 15 min) electromyography biofeedback training. Quantitative electroencephalography analysis was performed to obtain the absolute power of the four main frequency bands. Pain scores before and after electromyography biofeedback were also evaluated by subjective rating. [Results] Electromyography biofeedback increased alpha power and decreased delta power 15 minutes after training, suggestive of relaxation. However, although a tendency for scores to decrease was observed, no significant improvements in pain scores were observed following the intervention. Such results may be due to the short duration of the biofeedback session and the subjective nature of pain assessments. [Conclusion] Despite no obvious changes in pain perception, brief electromyography biofeedback training may induce relaxation in patients with myofascial pain syndrome of the upper trapezius muscle.
... 12 Nyeri miofasial servikal muncul karena adanya MTrPs pada otot dan fasia. 13 Kriteria penting untuk diagnosis MTrPs menurut Simon meliputi adanya taut band pada palpasi, nyeri lokal ketika nodul pada taut band ditekan, nyeri yang dirasakan oleh pasien sendiri ketika menekan nodul sensitif dan rasa nyeri tersebut membatasi amplitudo gerakan selama peregangan. 14,15 MTrPs aktif dianggap ada jika tiga dari empat kriteria tersebut ada. ...
Article
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Nyeri miofasial servikal (NMS) merupakan sumber nyeri umum pada individu dengan nyeri leher kronik nonspesifik. Nyeri dapat bersifat lokal, regional dan dapat juga memiliki banyak titik pemicu nyeri (myofascial trigger points/MTrPs). NMS menyebabkan nyeri di daerah otot servikal maupun fasia di sekitarnya. Nyeri leher menurunkan kualitas hidup, menurunkan produktivitas dan menyebabkan disabilitas sehingga berpengaruh secara sosioekonomi terhadap penderita dan masyarakat.Pengobatan sindrom nyeri miofasial servikal masih belum memuaskan terkait kronisitasnya. Dry needling (DN) adalah salah satu pilihan terapi nonfarmakologi yang bisa diterapkan pada NMS. DN akan mengurangi sensitisasi perifer dan sentral dengan menghilangkan sumber nosisepsi perifer (area MTrPs), memodulasi aktifitas kornu dorsalis dan mengaktifkan jalur inhibisi nyeri sentral.Neurolog sering menangani kasus NMS dan perkembangan DN akhir-akhir ini semakin pesat sebagai manajemen nyeri. Namun, keefektifan terapi DN masih belum jelas. Oleh karena itu, pengetahuan tentang peran DN pada NMS ini penting untuk diketahui oleh para neurolog. Artikel kami akan membahas tentang peran DN pada sindrom nyeri miofasial servikal.Kata kunci: Dry needling, nyeri miofasial servikal, terapi, myofascial trigger point
... David Simons [7] defined MPS as a complex of sensory, motor, and autonomic symptoms that are caused by MTrPs; this definition remains widely accepted [8]. The most commonly used diagnostic criteria date back to 1999, as proposed by Simons et al. [6]. ...
Article
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Purpose of review: We discuss the need for a mechanism-based diagnostic framework with a focus on the development of objective measures (e.g., biomarkers) that can potentially be added to the diagnostic criteria of the syndrome. Potential biomarkers are discussed in relation to current knowledge on the pathophysiology of myofascial pain syndrome (MPS), including alterations in redox status, inflammation, and the myofascial trigger point (MTrP) biochemical milieu, as well as imaging and neurophysiological outcomes. Finally, we discuss the long-term goal of conducting a Delphi survey, to assess the influence of putative MPS biomarkers on clinician opinion, in order to ultimately develop new criteria for the diagnosis of MPS. Recent findings: Myofascial pain syndrome (MPS) is a prevalent healthcare condition associated with muscle weakness, impaired mood, and reduced quality of life. MPS is characterized by the presence of myofascial trigger points (MTrPs): stiff and discrete nodules located within taut bands of skeletal muscle that are painful upon palpation. However, physical examination of MTrPs often yields inconsistent results, and there is no gold standard by which to diagnose MPS. The current MPS diagnostic paradigm has an inherent subjectivity and the absence of correlation with the underlying pathophysiology. Recent advancements in ultrasound imaging, systemic biomarkers, MTrP-specific biomarkers, and the assessment of dysfunction in the somatosensorial system may all contribute to improved diagnostic effectiveness of MPS.
... MPS is a common cause of acute and chronic pain in the general population, most commonly observed as a primary phenomenon. Myofascial pain may also present as a secondary phenomenon, when provoked by such processes as inflammation, infection, or tumors (11). ...
Article
Pancreatic cancer is often accompanied by severe pain. Patients typically experience upper abdominal and/or thoracolumbar back pain. For those cases failing to respond to standard medical management, as suggested by the World Health Organization, interventions designated at interruption of the sympathetic axis (such as neurolysis of the celiac plexus or splanchnic nerves) have been shown to be efficacious. Other than axial drug delivery, there are few interventional alternatives in patients with pancreatic cancerrelated pain. There is little knowledge regarding the therapeutic effects of treating peripheral somatic soft tissue among oncological patients. Here we report on 2 such patients, whose back pain improved following a quadratus lumborum block. Two patients diagnosed with pancreatic cancer presented with severe back pain. The pain pattern and patients’ physical exams were compatible with myofascial pain arising from the quadratus lumborum muscle, possibly irritated by the abdominal tumor. Advanced pain management, including long- and short-acting opioids and adjuvants, as well as celiac plexus neurolytic block, failed to provide satisfactory pain relief. Given the apparent muscular origin of the pain, a bilateral ultrasound-guided quadratus lumborum block was performed. Four weeks post procedure, the 2 patients reported substantial pain relief supported by reduced consumption of pain medication and improved functional status. No adverse events or complications were observed in either case. In the patients described here, quadratus lumborum block proved to be safe and efficacious in alleviating back pain related to pancreatic cancer. In our opinion, clinicians should be aware of the possible contribution of a myofascial component to pain in pancreatic cancer and in cancer-related pain in general. Key words: Quadratus lumborum block, cancer pain, pancreatic cancer, pain control, myofascial pain syndrome, interventional pain management
... Simons wskazał większe i mniejsze kryteria diagnostyczne punktów spustowych, zgodnie z którymi zespół bólu mięśniowo--powięziowego można zdiagnozować, jeśli spełnionych jest pięć głównych kryteriów i co najmniej jedno z trzech mniej istotnych kryteriów. Główne kryteria obejmują: zlokalizowany spontaniczny ból, spontaniczny ból lub zmienione odczucia w oczekiwanym obszarze rzutowania dla danego punktu spustowego (obszar docelowy), napięte, wyczuwalne zgrubienie w dostępnym mięśniu, zlokalizowaną tkliwość w precyzyjnym punkcie wzdłuż napiętego pasma oraz pewien stopień zmniejszonego zakresu ruchu, gdy jest to mierzalne [21]. W 2007 r. ...
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Introduction and Objective. The myofascial pain syndrome (MPS) is an important clinical problem which, despite numerous scientific reports, remains not fully understood. This refers in particular to unclearly stated pathomechanism and undefined diagnostic and therapeutic standards. In daily clinical practice, palpation is the most commonly applied method of myofascial pain syndrome diagnostics. However, this may be associated with inaccurate diagnosis. Therefore, the diagnosis of myofascial pain syndrome requires reliable, repeatable measurements which should be characterized by high sensitivity in order to detect clinically important changes. The aim of this study is to review the objective diagnostic methods essential for the correct diagnosis of myofascial pain syndrome. Brief description of the state of knowledge. The progress of clinical medicine depends on the ability to accurately diagnose the disease and objectively assess the effects of the treatment. Therefore, it seems crucial to develop effective, objective methods for diagnosing myofascial pain syndrome. Currently, there is no consensus among clinicians regarding the myofascial pain syndrome diagnostic procedure. Conclusion. Manual palpation performed by an experienced physiotherapist seems to be the most reliable examination, followed by establishing the Simons’ diagnostic criteria on its basis, together with supporting the diagnosis using one of the objective tools assessing changes in muscle tissue suggesting the presence of trigger points.
... The distinction between active and latent MTrPs is based on the reproduction of the patient's symptoms. Currently, the only method available for the clinical diagnosis of myofascial pain is physical examination including palpation and the patients' response [8][9][10], as other methods (biomarkers, electrodiagnostic testing, imaging, microdialysis, magnetic resonance elastography, etc.) are not practical for clinical use [11][12][13]. Hence reliable MTrP physical examination is a necessary prerequisite for considering myofascial pain as a valid diagnosis [14]. ...
Article
Background: Myofascial trigger point diagnosis is a clinical palpatory skill dependent on the patient's subjective response. The inter- and intra-rater reliability of trigger point physical evaluation in the lower leg muscles has rarely been reported. Previous reliability studies suffered from the Kappa paradox. Objective: To evaluate the inter- and intra-rater reliability of trigger point recognition in the lower leg muscles implying a specific method to overcome the 1st Kappa paradox. Design: A reliability study with pre-second examiner exclusion to correct prevalence index. Setting: Physical therapy outpatient clinic, Beer-Sheva, Israel. Subjects: 86 soldiers aged 18-30 referred for physical therapy with a diagnosis of musculoskeletal pain consented to take part in this study. 26 were excluded for lacking trigger points, leaving 60 subjects for analysis (31 women, 29 men). Methods: Both legs were evaluated, and the results were analyzed separately for symptomatic (N = 87) and asymptomatic legs (N = 31).Each subject was evaluated three times, twice by one examiner, and once by a second examiner. Dichotomous findings including palpable taut-band, tenderness, referred pain, and relevance of referred pain were recorded. Results: Inter-rater reliability for active trigger points ranged from 0.49 to 0.75 (median: 0.52) and intra-rater reliability ranged from 0.41 to 0.84 (median: 0.65) and. For total trigger points intra-rater reliability ranged from 0.52 to 0.79 (median: 0.67), and inter-rater reliability ranged from 0.44 to 0.77 (median: 0.66). Conclusions: Physical examination is a reliable method of trigger point evaluation in lower leg muscles, and it can be used as a diagnostic method for trigger point evaluation.
... Myofascial pain syndrome is widely recognized as a common source of pain in musculoskeletal medicine. Muscle and nerve components of this syndrome, i.e., motor, sensory, and autonomic, have been studied over the years (Eng-Ching, 2007;Shah and Gilliams 2008;Borg-Stein and Simons 2002;Bennett 2007;Giamberardino et al., 2011). The association of myofascial pain with various musculoskeletal morbidities has been demonstrated in numerous studies (Saxena 2015; Fern andez-de-las-Peñas 2015; Dor and Kalichman 2017;Shmushkevich and Kalichman 2013;Sergienko and Kalichman 2015;Lisi et al., 2015). ...
Article
Background The fascial component of the myofascial pain syndrome and the contribution of the deep fascia to various painful conditions has not been well-described and is still less understood. Objectives The aims of this study were to evaluate the possible role of the deep fascia on musculoskeletal pain, focusing on findings from histological and experimental studies; and to assess the nociceptive and associated responses of the deep fascia to experimentally-induced irritation. Methods Narrative review of the English scientific literature. Results and conclusions Different components of the deep fascia, both in humans and animals are richly innervated, with some differences between body segments. These fascial components usually exhibit dense innervation, encompassing amongst others, nociceptive afferents. The application of different types of stimuli, i.e., electrical, mechanical, and chemical to these fascial components produces long-lasting pain responses. In some cases, the intensity and severity of pain produced by the stimulation of fascia were higher than ones produced by the stimulation of the related muscular tissue. These observations may denote that the deep fascia and its various components could be a source of pain in different pathologies and various pain syndromes.
... Limitations of the study are the small sample size, the use of a single center, and use only 1 type of transcranial stimulation. The next important limitation of this study is that the patients were not screened specifically for the presence of myofascial trigger points with respect to facial myofascial syndrome [23]. ...
Article
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BACKGROUND Infrared thermography is a diagnostic method used to monitor acute and chronic orofacial pain syndrome. Repetitive transcranial magnetic stimulation (rTMS) is a form of non-invasive brain stimulation. This prospective study from a single center aimed to investigate the effects of rTMS and used infrared thermography as a confirmatory test of orofacial pain. MATERIAL AND METHODS We used infrared thermography to examine the incidence of inflammatory changes as orofacial pain triggers. During the analysis of rTMS effects on patients with orofacial pain, we compared the decrease in pain and the thermal difference in the study group (n=17) and in the research group (n=13). RESULTS In the control group (n=13), there were no statistically significant changes. Both groups showed a significant decrease in self-reported pain. Numerical pain rating scores were significantly lower after S2 stimulation than after S1/M1 (P=0.0071) or sham (P=0.0187) stimulation. The Brief Pain Inventory scores were also lower 3 to 5 days after S2 stimulation than at the pretreatment baseline (P=0.0127 for the intensity of pain and p=0.0074 for the interference of pain), and after S1/M1 (P=0.001 and P=0.0001) and sham (P=0.0491 and P=0.0359) stimulations. CONCLUSIONS The findings from this study support the role of infrared thermography for the diagnosis of chronic orofacial pain, and showed that on the first and fifth days of rTMS therapy in the study group there was a significant reduction of the thermography findings when compared with the control group without rTMS therapy.
... 8 Acute or chronic stress, microtrauma, poor posture, misuse of muscles, sedentary lifestyle, nutritional deficiencies, and infections are major risk factors for the development of myofascial pain syndrome. 9 The imbalance in the paraspinal muscles may lead to poor posture and development of myofascial pain syndrome as observed by our study. ...
Article
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BACKGROUND Scoliotic spine puts undue strain on the back musculature which may lead to the production of myofascial pain syndrome (MPS). The purpose of this study was to find out the association of myofascial pain of iliopsoas and quadratus lumborum in scoliotic patients and to look for any correlation between the degree of deformity (Cobb’s angle) and severity of myofascial pain. METHODS A total of 60 patients of low back pain with spinal deformity were enrolled in the study. The severity of the spinal deformity and pain was calculated with Cobb’s angle and visual analogue scale (VAS) pain scale (0 - 100) respectively. Patients with iliopsoas and quadratus myofascial pain underwent trigger point therapy along with regimen of stretching exercises. VAS scores were recorded at 0 - hour, 2 - hour, 2 - weeks, 1 month and 3 months after the procedure. RESULTS Forty-four patients out of 60 had myofascial pain of iliopsoas or quadratus lumborum or both. 15, 31 and 12 patients had Cobb’s angle of 10 - 20, 21 - 30 and 31 - 40 degree, respectively. Trigger point injections were performed in 38 patients. The pre-procedure median VAS score was 70, at 0 hour 45, at 2 hour 40, at 2 weeks 30, at 1 month 30 and at 3 months 30. A significant reduction (P < 0.001) in VAS score was observed till 3 months. CONCLUSIONS The myofascial pain of iliopsoas and quadratus lumborum is an important source of low back pain in patients with scoliosis. There is no correlation between the degree of scoliosis and severity of low back pain. KEYWORDS Scoliosis, Kyphoscoliosis, Thoraco-Lumbar Spinal Deformity, Myofascial Pain, Iliopsoas, Psoas Major, Quadratus Lumborum, Low Back Pain
... Treatment of myofascial pain is based on inactivating the MTrPs. The most common conservative interventions for this purpose are ischemic compression and dry needling (Cummings and Baldry, 2007;Giamberardino et al., 2011). However, to the best of our knowledge, VT has never been employed as a treatment alternative for MTrPs. ...
Article
Background The purpose of this study was to evaluate the effect of low-frequency self-administered vibration therapy into myofascial trigger points in the upper trapezius and levator scapulae on patients with chronic non-specific neck pain. Methods Twenty-eight patients with chronic non-specific neck pain were randomly assigned into a vibration group, receiving 10 self-applied sessions of vibration therapy in the upper trapezius and levator scapulae trigger points; or a control group, receiving no intervention. Self-reported neck pain and disability (Neck Disability Index) and pressure pain threshold were assessed at baseline and after the first, fifth and 10th treatment sessions. Findings Significant differences were found in the vibration group when compared to the control group after the treatment period: the vibration group reached lower Neck Disability Index scores (F = 4.74, P = .033, η² = 0.07) and greater pressure pain threshold values (F = 7.56, P = .01, η² = 0.10) than the control group. The vibration group reported a significant reduction in Neck Disability Index scores (F = 22.78, P = .00, η² = 0.37) and an increase in pressure pain threshold (F = 64.29, P = .00, η² = 0.62) between the assessment times over the course of the treatment. The mean increase in pressure pain threshold in the vibration group after the 10 sessions was 8.54 N/cm2, while the mean reduction in Neck Disability Index scores was 4.53 points. Interpretation Vibration therapy may be an effective intervention for reducing self-reported neck pain and disability and pressure pain sensitivity in patients with chronic non-specific neck pain. This tool could be recommended for people with non-specific neck pain.
... [25] This seems also notable given the consideration of MPS as the most frequent, but at the same time the most often under-diagnosed or misdiagnosed pain condition, despite the availability of effective therapeutic interventions for MPS when properly identified. [37] In a previous study among 72 patients with cervicogenic dizziness, MPS in the face, neck and shoulders was reported in 97% of patients along with improvement in dizziness symptoms via treatment for MPS in 70% patients. [13] The authors also noted a significant difference in the distribution of trigger points between cervicogenic dizziness patients and MPS patients without dizziness, with a higher rate of trigger points in the lateral neck muscles and involvement of sternocleidomastoid muscle only among cervicogenic dizziness patients. ...
Article
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Objectives: This study aims to investigate the prevalence, etiology, and risk factors of cervicogenic dizziness in patients with neck pain. Patients and methods: Between June 2016 and April 2018, a total of 2,361 patients (526 males, 1,835 females; mean age: 45.0±13.3 years; range, 18 to 75 years) who presented with the complaint of neck pain lasting for at least one month were included in this prospective, cross-sectional study. Data including concomitant dizziness, severity, and quality of life (QoL) impact of vertigo (via Numeric Dizziness Scale [NDS]), QoL (via Dizziness Handicap Inventory [DHI]), mobility (via Timed Up-and-Go [TUG] test), balance performance [via Berg Balance Scale [BBS]), and emotional status (via Hospital Anxiety- Depression Scale [HADS]) were recorded. Results: Dizziness was evident in 40.1% of the patients. Myofascial pain syndrome (MPS) was the most common etiology for neck pain (58.5%) and accompanied with cervicogenic dizziness in 59.7% of the patients. Female versus male sex (odds ratio [OR]: 1.641, 95% CI: 1.241 to 2.171, p=0.001), housewifery versus other occupations (OR: 1.285, 95% CI: 1.006 to 1.642, p=0.045), and lower versus higher education (OR: 1.649-2.564, p<0.001) significantly predicted the increased risk of dizziness in neck pain patients. Patient with dizziness due to MPS had lower dizziness severity scores (p=0.034) and milder impact of dizziness on QoL (p=0.005), lower DHI scores (p=0.004), shorter time to complete the TUG test (p=0.001) and higher BBS scores (p=0.001). Conclusion: Our findings suggest a significant impact of biopsychosocial factors on the likelihood and severity of dizziness and association of dizziness due to MPS with better clinical status.
... MTrPs are foci of muscles that have intense sensitivity and irritability, are located predominantly near the motor end plates, and have palpable tensile band characteristics mediated by the local response of reflex muscle contraction upon palpation of muscle fibers. Increased local irritability gives rise to pain and sensory changes that may be local or referred [7,8]. e integrated MTrPs hypothesis postulates that, in myofascial pain, the motor endplates release excessive acetylcholine which is evidenced histopathologically by the presence of sarcomere shortening [9]. ...
Article
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Myofascial pain syndrome is characterized by pain and a limited range of joint motion caused by muscle contracture related to motor-end-plate dysfunction and the presence of myofascial trigger points (MTrPs). It is the most frequent cause of musculoskeletal pain, with a worldwide prevalence varying between 13.7% and 47%. Of the patients with myofascial pain syndrome, approximately 17% have pain in the medial hindfoot area. The abductor hallucis muscle is located in the medial, posterior region of the foot and is related to painful plantar syndromes. The objective of this study was to describe the distribution of the medial plantar nerve and their anatomical relationship with MTrPs found in the literature. Thirty abductor hallucis muscles were dissected from 15 human cadavers (8 males and 7 females). The muscles were measured, and the distribution data of the medial plantar nerve branches in each quadrant were recorded. For statistical analysis, we used generalized estimation equations with a Poisson distribution and a log logarithm function followed by Bonferroni multiple comparisons of the means. The data are expressed as the mean ± standard deviation. The level of significance was adjusted to 5% (p
... The primary known therapeutic effects are releasing muscular contractions and alleviating the vicious pain cycle [54][55][56]. Injection treatment of MPS with local anesthetics is reported to be highly effective and currently represents the gold standard [57]. The local anesthetics are thought to bring relief from muscle tightness. ...
Article
The serratus anterior muscle is commonly involved in myofascial pain syndrome and is treated with many different injective methods. Currently, there is no definite injection point for the muscle. This study provides a suggestion for injection points for the serratus anterior muscle considering the intramuscular neural distribution using the whole-mount staining method. A modified Sihler method was applied to the serratus anterior muscles (15 specimens). The intramuscular arborization areas were identified in terms of the anterior (100%), middle (50%), and posterior axillary line (0%), and from the first to the ninth ribs. The intramuscular neural distribution for the serratus anterior muscle had the largest arborization patterns in the fifth to the ninth rib portion of between 50% and 70%, and the first to the fourth rib portion had between 20% and 40%. These intramuscular neural distribution-based injection sites are in relation to the external anatomical line for the frequently injected muscles to facilitate the efficiency of botulinum neurotoxin injections. Lastly, the intramuscular neural distribution of serratus anterior muscle should be considered in order to practice more accurately without the harmful side effects of trigger-point injections and botulinum neurotoxin injections.
... It is a very small, localized area of muscle contraction that is hard to touch; very tender; painful on compression, stretch, overload, or contraction of the muscle. It is usually prevalent in levator scapulae, upper trapezius, sternocleidomastoid and scalenes muscles (Giamberardino et al. 2011). These regions are involved in maintaining posture and work consistently against gravity or repetitively during daily activities (Borg-Stein and Simons 2002;Fernandez-de-las-Penas et al., 2005). ...
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Introduction The stretching intervention of the current study was applied from several principles and the latest updates method slowed and synchronized pattern between self-stretching with mindful breathing (MB) and eyes closed period before and after the self-stretching performed at least four times repeatedly within 150 s per each pose. Objective To investigate effects of self-stretching in five poses with and without MB on pain and cervical range of motion (CROM). Design The study was a randomized clinical trial with a blinded assessor. Setting The participants were 30 females per group, aged 30–59 years with Myofascial pain syndrome (MPS). Main outcome measures The participants were evaluated the pressure pain threshold (PPT) at upper trapezius muscles and evaluated CROM. Results Both groups showed that the PPT at upper trapezius muscles were a significant increase after performing the stretching (p < 0.001). For the ROM in the MB group significantly increased in extension, left and right lateral flexion and left rotation (p < 0.05). Conclusion The self-stretching with mindful breathing was designed to be appropriate to investigate effects within the shortest time immediately in Myofascial pain syndrome. Since, this treatment is non-pharmacological intervention and was considered as a part of active self-care, thus we suggest that could be used as alternative therapy for patients with MPS.
... Los estudios utilizaron puntos gatillo, hallados por palpación manual, como el estándar de referencia, lo que significa que el propósito de estos estudios fue identificar los mecanismos fisiológicos subyacentes detrás de la presencia de puntos gatillo más que una validación diagnóstica de los hallazgos de la palpación. Se han sugerido varias teorías hipotéticas para explicar la formación y persistencia de los puntos gatillo [156] . Es un tema de controversia si los puntos gatillo se deben considerar como entidades independientes que constituyen una fuente primaria de dolor o si son secundarias a otros trastornos dolorosos [106,157] . ...
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Background: Women with dysmenorrhea plus symptomatic urinary calculosis experience enhanced pain and referred muscle hyperalgesia from both conditions than women with one condition only (viscero-visceral hyperalgesia). The study aimed at verifying if enhanced dysmenorrhea persists after urinary stone elimination in comorbid women and if local anesthetic inactivation of myofascial trigger points (TrPs) in the lumbar area (of urinary pain referral) also relieves dysmenorrhea. Methods: 31 women with dysmenorrhea plus previous urinary calculosis (Dys+PrCal) and lumbar TrPs, and 33 women with dysmenorrhea without calculosis (Dys) underwent a 1-year assessment of menstrual pain and muscle hyperalgesia in the uterus referred area (electrical pain threshold measurement in rectus abdominis, compared with thresholds of 33 healthy controls). At the end of the year, 16 comorbid patients underwent inactivation of TrPs through anesthetic injections, while the remaining 12 received no TrP treatment. Both groups were monitored for another year at the end of which thresholds were re-measured. Results: In year1, Dys+PrCal presented significantly more painful menstrual cycles and lower abdominal thresholds than Dys, thresholds of both groups being significantly lower than normal (p<0.001). Anesthetic treatment vs no treatment of the lumbar TrP significantly reduced the number of painful cycles during year2 and significantly increased the abdominal thresholds (p<0.0001). Conclusion: Viscero-visceral hyperalgesia between uterus and urinary tract may persist after stone elimination due to nociceptive inputs from TrPs in the referred urinary area, since TrPs treatment effectively reverses the enhanced menstrual symptoms. The procedure could represent an integral part of the management protocol in these conditions.
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Background Myofascial neck and back pain is an increasingly common chief symptom in the emergency department. Currently, there are no widely accepted conventional therapies, and there is little evidence on the efficacy of interventions such as trigger point injections (TPIs). Objective This study evaluates whether TPIs with 1% lidocaine can improve myofascial back and neck pain compared with conventional therapies. Secondary outcomes include changes in length of stay and number of opioid prescriptions on discharge. Methods This single-center, prospective, randomized, pragmatic trial was carried out in patients clinically determined to have myofascial back or neck pain. Patients were randomized into the experimental arm (TPI with 1% lidocaine) or the control arm (standard conventional approach). Numeric Rating Scores (NRS) for pain and additional surveys were obtained prior to and 20 min after the intervention. Results The NRS for pain was lower in the TPI group compared with the control group after adjustment for initial pain (median difference –3.01; 95% confidence interval –4.20 to –1.83; p < 0.001). Median length of stay was 2.61 h for the TPI group and 4.63 h for the control group (p < 0.001). More patients in the control group (47.4%) were discharged home with an opioid compared with the TPI group (2.9%) (p < 0.001). Conclusions TPI is an effective method for managing myofascial pain in the emergency department. This study indicates it may improve pain compared with conventional methods, reduce length of stay in the emergency department, and reduce opioid prescriptions on discharge.
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Introduction Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management. Objectives This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options. Methods A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords “chronic pelvic pain,” “neuropathy,” “neuropathic pain,” “retroperitoneal schwannoma,” “pudendal neuralgia,” and “entrapment syndromes.” Results Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning. Conclusion Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services. Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022;XX:XXX–XXX.
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Objective There were two goals to this study: the first goal was to research the analgesic effectiveness of erector spinae plane block (ESPB) added to the treatment after trapezius muscle injection (TMI) and the second was to investigate whether repeated TMI increases the analgesic effect in myofascial pain syndrome (MPS). Methods Sixty patients with a diagnosis of MPS were randomized into two groups. The TMI group (n = 30) received ultrasound‐guided (USG) TMI with 5 mL of 0.25% bupivacaine two times, with a 1‐week interval in between. The ESPB group (n = 30) received USG TMI with 5 mL of 0.25% bupivacaine in the first week and USG ESPB with 20 mL of 0.125% bupivacaine in the second week. The pain severity of the patients was evaluated using the visual analog scale (VAS). The data obtained before (week 0) and after (weeks 1, 2, 3, and 4) the injections were statistically compared between the groups. Results In both groups, the mean VAS score decreased in the first week compared to the mean pretreatment score (p < .001). When the VAS scores were compared between the first and second weeks, a decrease was observed in both groups (p < .001), but it was more evident in the ESPB group. Compared to previous weeks, there was no significant difference in VAS scores at the third and fourth weeks. Conclusions The analgesic effect of repeated TMI for MPS was superior to a single injection, but ESPB combined with TMI provided more effective analgesia than repeated TMI.
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İnmeli hastalarda santral nöropatik ağrı değerlendirilmesi ve yaşam kalitesi ile ilişkisi
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SARS-CoV-2 is a novel virus that has caused a plethora of dysfunctions and changes in the human body. Our goal in this case study series was to demonstrate the relationship that coronavirus has had in newly diagnosing patients with myofascial pain syndrome (MFPS). Medical records were obtained from a pain clinic that demonstrated the effects of this virus on patients who developed MFPS between March 2020 and December 2020. Chart reviews were performed and demonstrated patients who had a history of chronic pain had subsequent episodes of worsening exacerbations of pain, more specifically trigger points, after being diagnosed with coronavirus. MFPS and SARS-CoV-2 are proposed to be correlated amongst chronic pain patients. Potential pathological mechanisms include coronavirus-induced hypoxic muscle dysfunctions as well as psychological stress triggering pain receptors, leading to myofascial pain syndrome.
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Introduction Masticatory myofascial pain syndrome can present similarly to other dental conditions in odontogenetic structures. Endodontists should be familiar with the symptomology and pathophysiology of masticatory myofascial pain syndrome to avoid misdiagnosis, incorrect treatment, and medicolegal repercussions. The aim of this review is to provide a foundational summary for endodontists to identify and correctly manage masticatory myofascial pain syndrome. Methods A narrative review of literature was performed through a Medline search and a hand search of the major myofascial pain textbooks. Results Masticatory myofascial pain syndrome is a musculo-ligamentous syndrome that can present similarly to odontogenic pain, or refer pain to the eyebrows, ears, temporomandibular joints, maxillary sinus, tongue, and hard palate. Currently, the most comprehensive pathophysiology theory describing masticatory myofascial pain syndrome is the expanded integrated hypothesis. The most widely accepted diagnostic guideline for masticatory myofascial pain syndrome are the Diagnostic Criteria for Temporomandibular Disorders; however, their diagnostic capability is limited. There is no hierarchy of treatment methods as each patient requires a tailored and multi-disciplinary management aimed at regaining the muscle’s range of motion, deactivating the myofascial trigger points, and maintaining pain relief. Conclusions The pain patterns for masticatory myofascial pain syndrome are well known; however, there is a lack of consensus on the most proper method of trigger point diagnosis or pain quantification. The diagnostic strategies for masticatory myofascial pain syndrome vary, and the diagnostic aids are not well developed.
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BACKGROUND AND AIM Quadratus lumborum trigger points developed in low back pain. The aim of this study was to compare Reciprocal Inhibition with Ischemic Pressure on the Trigger Point of Quadratus Lumborum muscle in Low Back Pain. METHODOLOGY A 6 month randomized controlled trial was conducted. Non probability Convenience sampling was used to select a sample 50 participants having low back pain with Quadratus lamborum trigger points placed into group1 and group 2 by lottery method. Group 1 was treated with reciprocal inhibition and ischemic pressure along with conventional therapy and group 2 was treated with ischemic pressure along with conventional therapy. The data collection tools were Numeric pain rating scale and Goniometer. Data was analyzed by statistical package for social science 21. Independent t-test used for between comparison analysis and Paired t-test was used for within analysis. RESULTS The numeric pain rating scale mean difference in group 1 and group 2 was 4.72±0.12, 5.13±0.13 respectively. The Quadratus lamborum muscle length mean difference in group 1 and group 2 was 8.95±1.67, 5.34±1.25 respectively. CONCLUSION The addition of reciprocal inhibition with ischemic pressure showed significant results. KEY WORDS reciprocal Inhibition, ischemic pressure, quadratus lumborum, Back Pain, Myofascial Trigger Point Pain, Articular Goniometry, range of motion
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Objective: The aim of this study was to evaluate the neuropathic pain component in patients with myofascial pain syndrome, and to examine the effects of neuropathic pain on emotional status, sleep and quality of life. Material and Methods: 73 patients with MPS in their neck or upper back region admitted to the tertiary university hospital were included. Questionnaires were administrated to the patients via face-to-face interviews, and included sociodemographic variables. The patients were evaluated for neuropathic component by DN4 questionnaires, and pain by visual analog scale (VAS). Validated questionnaires measuring emosyonel status, sleep quality and quality of life were used. Results: Of the 73 patients, 48 (65.8%) were female and 25 (34.2%) were male. The mean age of all recruited patients was 38.2±10.6 years. According to the DN4 scale 56.2% of the patients had neuropathic pain. MPS patients were divided into two groups as those with and without neuropathic pain. VAS, BDI, and PSQI scores were significantly higher among MPS patients with neuropathic pain than among MPS patients without neuropathic pain (p<0.01).The patients with neuropathic pain had lower scores for all the parameters of the SF-36. Morever vitality, social function, mental health, and emotional role dimensions scores were significantly lower in MPS patients with neuropathic pain than MPS patients without neuropathic pain (p<0.01). Conclusion: An appropriate diagnosis and treatment of the neuropathic pain plays an important role and can reduce the pain, improve the quality of life and sleep qulity, and decrease the level of depression in treatment of MPS.
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Despite extensive clinical research, temporomandibular disorders (TMD) remain a challenge. Controversies exist in the literature regarding the diagnosis and the management protocol for TMD. These disorders are patho-physiological conditions related to the masticatory muscles, temporomandibular joints or their associated structures and share main symptom expressions and clinical features. Symptoms commonly related to TMD are pain from the face and jaw area at rest or on function, jaw tiredness, TMJ sounds such as clicking or crepitation, jaw movement limitations and locking/catching or luxation of the mandible. Signs regarded as clinical indicators of TMD are tenderness upon palpation of the TMJs and the masticatory muscles, TMJ sounds and irregular paths of jaw movement, impaired jaw movement capacity and pain on jaw movement. Despite decades of research, a comprehensive etiological picture of TMD is still lacking. The variety of included conditions and the complexity of the masticatory system are reflected in the currently accepted multifactorial etiology. The balance between function and dysfunction or adaptation and maladaptation can be affected by a number of factors, such as external macrotrauma to the face, indirect trauma as in whiplash, or repeated micro-trauma, mostly related to oral parafunctions and psychosocial elements. These factors interact dynamically and can, in certain individual circumstances, act as predisposing or initiating elements, leading to the disturbed equilibrium and dysfunction of the masticatory system.
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Background Complicated diverticulitis in advanced stages (Hinchey III, IV) is an important surgical emergency for which Hartmann’s Procedure (HP) has traditionally represented the gold standard treatment. HP, however, has high mortality and morbidity and a low percentage of reanastomosis rate. Increasing efforts have therefore been made in recent years to propose alternatives. Objective To critically review studies on the outcome of HP vs. alternative procedures for complicated diverticulitis Resection-Anastomosis without [RA] or with [RAS] protective stomia, Laparoscopic Lavage [LL]. Methods Literature search in PubMed for original and review papers in the past 20 years (up to July 2019) with keywords: Hartmann’s procedure, complicated diverticulitis. Results Comparative studies on HP vs . RA/RAS overall reveal better outcomes of RA/RAS, i.e ., reduced mortality, morbidity and healthcare costs. However, most studies have limitations due to lack of randomization, limited number of patients and significant impact of surgeons’ specialization and hospital setting/organization in the decision of the type of surgery to perform. These factors might induce preferential allocation of the most critical patients (advanced age, hemodynamic instability, numerous comorbidities) to HP rather than RA/RAS. LL shows promising results but has been tested in a too small number of trials vs . HP to draw definite conclusions. Conclusion Though valid alternatives to HP are being increasingly employed, consensus on the best approach to complicated diverticulitis has not yet been reached. HP is still far from representing an obsolete intervention, rather it appears to be the preferred choice in the most critical patients.
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Myofascial pain is a common syndrome seen by family practitioners worldwide. It can affect up to 10% of the adult population and can account for acute and chronic pain complaints. In this clinical narrative review we have attempted to introduce dry needling, a relatively new method for the management of musculoskeletal pain, to the general medical community. Different methods of dry needling, its effectiveness, and physiologic and adverse effects are discussed. Dry needling is a treatment modality that is minimally invasive, cheap, easy to learn with appropriate training, and carries a low risk. Its effectiveness has been confirmed in numerous studies and 2 comprehensive systematic reviews. The deep method of dry needling has been shown to be more effective than the superficial one for the treatment of pain associated with myofascial trigger points. However, over areas with potential risk of significant adverse events, such as lungs and large blood vessels, we suggest using the superficial technique, which has also been shown to be effective, albeit to a lesser extent. Additional studies are needed to evaluate the effectiveness of dry needling. There also is a great need for further investigation into the development of pain at myofascial trigger points.
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Patients with muscle pain complaints commonly are seen by clinicians treating pain, especially pain of musculoskeletal origin. Myofascial trigger points merit special attention because its diagnosis requires examinations skills and its treatment requires specific techniques. If undiagnosed, the patients tend to be overinvestigated and undertreated, leading to chronic pain syndrome. Patients with myofascial pain syndrome present primarily with painful muscle(s) and restricted range of motion of the relevant joint. Palpable painful taut bands are named trigger points and are the main and pathognomonic finding on physical examination. Eliciting local twitch response and referred pain requires experience and examination skills. It may be useful to classify the patient as having acute or chronic, and as having primary or secondary, myofascial pain so the decision on the details of treatment can be curtailed to the needs of each patient. Effective treatment modalities are local heat and cold, stretching exercises, spray-and-stretch, needling, local injection, and high-power pain threshold ultrasound.
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Myofascial pain syndrome presents a significant physical and financial burden to society. In view of the aging demographics, myofascial pain promises to be an even greater challenge to health care in the future. Myofascial trigger points have been identified as important anatomic and physiologic phenomena in the pathophysiology of myofascial pain. While their pathophysiologic mechanisms are still unclear, emerging research suggests that trigger points may be initiated by neurogenic mechanisms secondary to central sensitization, and not necessarily by local injury. A variety of treatments are employed in the management of trigger points, including manual therapy, electrotherapy, exercise, and needle therapy. Therapeutic ultrasound demonstrates significant potential as a safe, cost-effective, and relatively noninvasive therapeutic alternative in the treatment and management of this modern day medical enigma.
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To test the hypothesis that dry needle stimulation of a myofascial trigger point (sensitive locus) evokes segmental anti-nociceptive effects. Double-blind randomized controlled trial. Forty subjects (21 males, 19 females). Test subjects received intramuscular dry needle puncture to a right supraspinatus trigger point (C4,5); controls received sham intramuscular dry needle puncture. Pain pressure threshold (PPT) readings were recorded from right infraspinatus (C5,6) and right gluteus medius (L4,5S1) trigger points at 0 (pre-needling baseline), 1, 3, 5, 10 and 15 min post-needling and normalized to baseline values. The supraspinatus and infraspinatus trigger points are neurologically linked at C5; the supraspinatus and gluteus medius are segmentally unrelated. The difference between the infraspinatus and gluteus medius PPT values (PPTseg) represents a direct measure of the segmental anti-nociceptive effects acting at the infraspinatus trigger point. Significant increases in PPTseg were observed in test subjects at 3 (p = 0.002) and 5 (p = 0.015) min post-needling, compared with controls. One intervention of dry needle stimulation to a single trigger point (sensitive locus) evokes short-term segmental anti-nociceptive effects. These results suggest that trigger point (sensitive locus) stimulation may evoke anti-nociceptive effects by modulating segmental mechanisms, which may be an important consideration in the management of myofascial pain.
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Three studies are presented demonstrating the reliability of the pressure algometer as an index of myofascial trigger point sensitivity. The first study showed high reliability between and within experimenters when measuring marked trigger point locations. In study 2, significant between experimenter reliability in locating and measuring the same unmarked trigger point locations was shown, while study 3 supported the idea that trigger points are discrete points of focal tenderness within the muscle. The ability to quantify and reliably measure trigger point sensitivity opens the door to a range of clinical and research possibilities for myofascial and related musculoskeletal pain problems.
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Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms.
Article
Background: Trigger points are promoted as an important cause Of musculoskeletal pain. There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points are conflicting. Objectives: To systematically review the literature on the reliability of physical examination for the diagnosis of trigger points. Methods: MEDLINE, EMBASE, and other sources were searched for articles reporting the reliability of physical examination for trigger points. Included studies were evaluated for their quality and applicability, and reliability estimates were extracted and reported. Results: Nine studies were eligible for inclusion. None satisfied all quality and applicability criteria. No study specifically reported reliability for the identification of the location of active trigger points in the muscles of symptomatic participants. Reliability estimates varied widely for each diagnostic sign, for each muscle, and across each Study. Reliability estimates were generally higher for subjective signs such as tenderness (kappa range. 0.22-1.0) and pain reproduction (kappa range, 0.57-1.00), and lower for objective signs Such as the taut band (kappa range, -0.08-0.75) and local twitch response (kappa range, -0.05-0.57). Conclusions: No Study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. On the basis of the limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot Currently be recommended its a reliable test for the diagnosis of trigger points. The reliability of trigger point diagnosis needs to be further investigated with Studies of high quality that use Current diagnostic criteria in clinically relevant patients.
Article
Patients affected with unilateral latent trigger points (lTPs) were examined, divided into two groups on the basis of the result of mechanical TP stimulation: group 1, patients who perceived local and referred pain; group 2, patients reporting only local pain. In all of them muscular and subcutaneous pain thresholds to electrical stimulation were measured at TP and target level and also in the contralateral non-affected areas. At TP level both muscular and subcutaneous thresholds were significantly lower than contralaterally in the two groups, but the phenomenon was far more accentuated in group 1. At target level muscular thresholds were significantly reduced in all patients but more in those of group 1; subcutaneous thresholds were significantly lowered in group 1 only. Threshold changes were more pronounced at TP than at target level in both groups. It is concluded that: esthesiological modifications are already present in the targets of TPs even in the preclinical phase, i.e. before the appearance of any spontaneous pain; these modifications seem to be related to the degree of TP irritability.
Article
Muscle pain has a tendency to be referred to other deep somatic tissues remote from the site of the original muscle lesion. Branching of primary afferent fibers does not seem to provide a satisfactory explanation for the referral. The convergence-projection theory of pain referral, in its original form, it is not applicable to muscle pain, since in dorsal horn neurons there is little convergence from deep tissues. Based on results from animal experiments a hypothetical explanation of muscle pain referral is proposed that adds two new components to the convergence-projection theory: convergent connections from deep tissues to dorsal horn neurons are not present from the beginning but are opened by nociceptive input from skeletal muscle, and referral to myotomes outside the lesion is due to spread of central sensitization to adjacent spinal segments.
Article
Objective: Myofascial pain syndromes associated with trigger points [TrPs] are an established clinical entity but the structural and functional abnormalities of TrPs are not well under stood. The aim of the study was to conduct a blinded electromyographic investigation of TrPs. Methods: Nineteen young subjects with chronic shoulder and arm pain, who had a TrP [i.e., a tender point with referred pain, producing at least some of the pain complaint] in the infraspinatus muscle, were examined. This point and a nontender control point in the same muscle were code-marked, in order to blind the examiner. Around both points 20 concentric needle electromyographic [EMG] recordings were obtained at rest. Results: More subjects had spontaneous EMG activity at the TrPs than at the control point. The EMG activity was interpreted as end-plate noise or spikes or both. The TrP Root Mean Square amplitudes were significantly higher than at the control points. Conclusion: Our investigation has demonstrated the presence of spontaneous EMG activity in myofascial TrPs, probably reflecting end-plate activity.
Article
Objective: This study is designed to investigate the amount of pressure on a myofascial pain trigger point [TrP] sufficient to initiate referred pain. Methods: Sensitive spots in palpable taut bands of extensor digitorum communis muscles in Group 1 subjects with latent TrPs [no spontaneous pain but tender] and in Group 2 patients with active TrPs [with spontaneous pain] were studied. A pressure algometer was used to measure the threshold of the pressure sufficient to induce local pain, referred pain and intolerable pain for each subject. The TrP [site A], a non-TrP location [site B] in the same taut band, and a control site in "normal" muscle tissue free of taut bands [site C] were measured. Results: It was found that the referred pain could be elicited with a higher incidence at site A [46.8% for a latent TrP; 100% for an active TrP] than at site B [36.2% for a latent TrP; 100% for an active TrP] than at site C [23.4% for a latent TrP; 68.0% for an active TrP]. For either a latent TrP or an active TrP, the mean pressure threshold to elicit a referred pain from site B was higher than from site A, but lower than from site C. For the same site, the pressure required to elicit referred pain was higher for a latent TrP than for an active TrP. There is a linear relationship between the pain threshold and the pressure threshold required to induce referred pain. The difference between pain threshold and referred pain threshold was less in an active TrP than in a latent one. In those cases when no referred pain could be elicited before reaching tolerance, the referred pain threshold was either higher than the threshold of pain tolerance or was absent at that site. Conclusion: It is concluded that a referred pain pattern can be induced more easily by compressing an active TrP than by compressing a less active or a latent one. The fact that the difference between pain threshold nd referred pain threshold is much less in an active TrP than in a latent TrP may be another useful sign to distinguish them clinically. Referred pain was reliably elicited by compression of an active TrP is adequate pressure was applied, but could not always be elicited by compression of a latent TrP. A similar referred pain could also be elicited by compressing sites near a TrP is enough pressure was applied. Therefore, referred pain is an appropriate sign to indicate an active TrP, but is not a reliable sign for the identification of a latent myofascial TrP.
Article
Objectives: The purpose of this article is to review the previously published data on myofascial trigger point injection and to present a proposed technique of myofascial trigger point [TrP] injection modified from tha described by Drs. Travell and Simons. Findings: Trigger point injection is an effective and valuable procedure to inactivate an active TrP, and subsequently relieve the pain and tightness of the muscle involved in myofascial pain syndrome. It is essential to elicit a local twitch response [LTR] during TrP injection to obtain the best results of immediate relief of pain. LTR is a brisk twitching of the muscle fibers of the taut band during mechanical stimulation [including needling] on the most sensitive site, the TrP region. Sometimes, other remote TrPs can also be inactivated if the "key TrP" is appropriately selected for injection based on skillfull clinical judgement. The trigger point injections are indicated for quick relief of acute, subacute, or chronic myofascial pain, for substitution of narcotic medicine, for restoration of functional impairment due to myofascial trigger points, or for supplementary therapy of chronic myofascial pain to facilitate its recovery. It is generally recommended to use 0.5% of procaine or lidocaine at a dose of 0.5-1.0 cc per TrP region for TrP injection. The proposed technique of TrP injection includes identification of the taut band containing the active TrP, skin preparation with sterile technique, rapid needle insertion into the multiple sites of a TrP region, injection of local anesthetic only if LTR is elicited, hemostatis, stretching and spray, and appropriate post-injection cares including cold or hot pack application, therapeutic exercise, therapeutic massage, and home program. The frequency and total number of injections should be determined based on clinical judgement. Some complications, such as muscle fiber damage, excessive bleeding, infection, syncope, or internal organ injury, may occur, but are usually preventable with careful and skillful injection technique. Conclusions: A technique of trigger point injection is proposed. Other than the traditional injection method, local twitch responses should be elicited as many times as possible during injection. The insertion of the needle should be quick to minimize muscle fiber damage. This technique is usually very effective to obtain immediate and complete pain relief.
Article
Objective. This systematic review assessed the available published evidence on the efficacy and safety of using trigger point injection (TPI) to treat patients with chronic non-malignant musculoskeletal pain that had persisted for at least 3 months. Methods. All published systematic reviews or randomized controlled trials detailing the use of TPI in patients with chronic, non-malignant musculoskeletal pain (persisting for >3 months) were identified by systematically searching literature databases and the Websites of various health technology assessment agencies, research registers, and guidelines sites up to July 2006. Results. Although no systematic reviews were identified, 15 peer-reviewed randomized controlled trials met the inclusion criteria. However, deficiencies in reporting, small sample sizes, and marked inter-study heterogeneity precluded a definitive synthesis of the data. TPI is a safe procedure when used by clinicians with appropriate expertise and training. It relieved symptoms when used as a sole treatment for patients with chronic head, neck, shoulder, and back pain or whiplash syndrome, regardless of the injectant used, and may be a useful adjunct to intra-articular injection in the treatment of osteoarthritis pain. Although the addition of TPI to stretching exercises augments treatment outcomes, this was also true of other therapies such as ultrasound and laser. Conclusion. The efficacy of TPI is no more certain than it was a decade ago as, overall, there is no clear evidence of either benefit or ineffectiveness. The only advantage of injecting anesthetic into trigger points may be to reduce the pain of the needling process, which may not be an insignificant benefit.
Article
Myofascial pain syndrome (MPS) is a common cause of acute and chronic pain that can complicate other medical illnesses and injuries. It is both defined by and diagnosed by the presence of the myofascial trigger point. Current studies indicate that the trigger point is a dysfunctional motor end plate whose abnormal activity is modulated in some way by the sympathetic nervous system. Pain syndromes arise from trigger points as causes of local pain and of referred pain. Referred pain from a few or from many muscle trigger points produces regional or generalized pain. Treatment requires the elimination of the trigger point by manual therapy or by trigger point injection and correction of the mechanical and medical factors that initiate and perpetuate it.
Article
We investigated the occurrence of active myofascial trigger points in specific muscle groups in relation to the existence of cervical disc bulging at various levels. One hundred and five patients (48 men, 57 women; mean age, 45.8 +/- 12.1 yr) who had active trigger points in the neck or upper back after trauma were divided into two groups on the basis of magnetic resonance imaging (MRI) evidence of bulging disc(s). The discN group consisted of 46 patients who had normal MRI findings in the cervical spine. The other 59 patients, with mild cervical disc bulging, were assigned to the disc' group. The correlations between specific muscles with active trigger points (clinical finding) and cervical disc lesions at specific levels (MRI finding) were analyzed. There were significant associations between the level of disc lesion and the muscles with trigger points, namely C3-4 lesions with levator scapulae and latissimus dorsi trigger points; C4-5 lesions with splenius capitis, levator scapulae, and rhomboid minor trigger points; C5-6 lesions with splenius capitis, deltoid, levator scapulae, rhomboid minor, and latissimus dorsi trigger points; and C6-7 lesions with latissimus dorsi and rhomboid minor trigger points. For each disc level, the average pain intensity (assessed using a numerical analog scale) of trigger points in certain correlated muscles (as indicated above) in the disc group was significantly higher than that in the discN group (p < 0.05 for all disc levels). We conclude that active trigger points are more likely to occur in certain muscles in the presence of cervical disc lesions at specific levels.
Article
Fibromyalgia syndrome (FS) frequently co-occurs with regional pain disorders. This study evaluated how these disorders contribute to FS, by assessing effects of local active vs placebo treatment of muscle/joint pain sources on FS symptoms. Female patients with (1) FS+myofascial pain syndromes from trigger points (n=68), or (2) FS+joint pain (n=56) underwent evaluation of myofascial/joint symptoms [number/intensity of pain episodes, pressure pain thresholds at trigger/joint site, paracetamol consumption] and FS symptoms [pain intensity, pressure pain thresholds at tender points, pressure and electrical pain thresholds in skin, subcutis and muscle in a non-painful site]. Patients of both protocols were randomly assigned to two groups [34 each for (1); 28 each for (2)] to receive active or placebo local TrP or joint treatment [injection/hydroelectrophoresis] on days 1 and 4. Evaluations were repeated on days 4 and 8. After therapy, in active--but not placebo-treated-- groups: number and intensity of myofascial/joint episodes and paracetamol consumption decreased and pressure thresholds at trigger/joint increased (p<0.001); FS pain intensity decreased and all thresholds increased progressively in tender points and the non-painful site (p<0.0001). At day 8, all placebo-treated patients requested active local therapy (days 8 and 11) vs only three patients under active treatment. At a 3-week follow-up, FS pain was still lower than basis in patients not undergoing further therapy and had decreased in those undergoing active therapy from day 8 (p<0.0001). Localized muscle/joint pains impact significantly on FS, probably through increased central sensitization by the peripheral input; their systematic identification and treatment are recommended in fibromyalgia.
Article
SUMMARY: Our aim was to analyze the differences in the referred pain patterns and size of the areas of those myofascial trigger points (TrPs) involved in chronic tension type headache (CTTH) including a number of muscles not investigated in previous studies. Thirteen right handed women with CTTH (mean age: 38 ± 6 years) were included. TrPs were bilaterally searched in upper trapezius, sternocleidomastoid, splenius capitis, masseter, levator scapulae, superior oblique (extra-ocular), and suboccipital muscles. TrPs were considered active when both local and referred pain evoked by manual palpation reproduced total or partial pattern similar to a headache attack. The size of the referred pain area of TrPs of each muscle was calculated. The mean number of active TrPs within each CTTH patient was 7 (95% CI 6.2-8.0). A greater number (T = 2.79; p = 0.016) of active TrPs was found at the right side (4.2 ± 1.5) when compared to the left side (2.9 ± 1.0). TrPs in the suboccipital muscles were most prevalent (n = 12; 92%), followed by the superior oblique muscle (n =11/n = 9 right/left side), the upper trapezius muscle (n = 11/n = 6) and the masseter muscle (n = 9/n=7). The ANOVA showed significant differences in the size of the referred pain area between muscles (F = 4.7, p = 0.001), but not between sides (F = 1.1; p = 0.3): as determined by a Bonferroni post hoc analysis the referred pain area elicited by levator scapulae TrPs was significantly greater than the area from the sternocleidomastoid (p = 0.02), masseter (p = 0.003) and superior oblique (p = 0.001) muscles. Multiple active TrPs exist in head, neck and shoulder muscles in women with CTTH. The referred pain areas of TrPs located in neck muscles were larger than the referred pain areas of head muscles. Spatial summation of nociceptive inputs from multiple active TrPs may contribute to clinical manifestations of CTTH.
Article
Many treatments have been proposed for myofascial pain syndrome. The objective of this study was to compare the analgesic effect of acupuncture to trigger point injection combined with cyclobenzaprine chlorhydrate and sodium dipyrone. A randomized study was performed in 30 patients divided into 2 groups: G1 received trigger point injection with 0.25% bupivacaine twice weekly, and both cyclobenzaprine chlorhydrate 10 mg/day and sodium dipyrone 500 mg every 8 hours; G2 received classical and trigger point acupuncture twice weekly. All patients were instructed in physical exercise. The following parameters were evaluated: pain intensity rated on a numerical scale, number of trigger points, and quality of life before and 4 weeks after treatment. The pain scores and the number of trigger points reduced significantly in both groups, with no significant difference between groups. Significant improvement in the quality of life scores was observed for some of the functional domains in the 2 groups, whereas there was no improvement of the general health status domain in either group or of the emotional domain in G1. Acupuncture, when compared with trigger point injection, combined with cyclobenzaprine chlorhydrate and sodium dipyrone provided similar pain relief and improvement in quality of life measures at 4 weeks. 
Article
Co-existing algogenic conditions in two internal organs in the same patient may mutually enhance pain symptoms (viscero-visceral hyperalgesia). The present study assessed this phenomenon in different models of visceral interaction. In a prospective evaluation, patients with: (a) coronary artery disease (CAD)+gallstone (Gs) (common sensory projection: T5); (b) irritable bowel syndrome (IBS)+dysmenorrhea (Dys) (T10-L1); (c) dysmenorrhea/endometriosis+urinary calculosis (Cal)(T10-L1); and (d) gallstone+left urinary calculosis (Gs+LCal) (unknown common projection) were compared with patients with CAD, Gs, IBS, Dys or Cal only, for spontaneous symptoms (number/intensity of pain episodes) over comparable time periods and for referred symptoms (muscle hyperalgesia; pressure/electrical pain thresholds) from each visceral location. In patients' subgroups, symptoms were also re-assessed after treatment of each condition or after no treatment. (a) CAD+Gs presented more numerous/intense angina/biliary episodes and more referred muscle chest/abdominal hyperalgesia than CAD or Gs; cardiac revascularization or cholecystectomy also reduced biliary or cardiac symptoms, respectively (0.001<p<0.05). (b) IBS+Dys had more intestinal/menstrual pain and abdomino/pelvic muscle hyperalgesia than IBS or Dys; hormonal dysmenorrhea treatment also reduced IBS symptoms; IBS dietary treatment also improved dysmenorrhea (0.001<p<0.05) while no treatment of either conditions resulted in no improvement in time of symptoms from both. (c) Cal+Dys had more urinary/menstrual pain and referred lumbar/abdominal hyperalgesia than Cal or Dys; hormonal dysmenorrhea treatment/laser treatment for endometriosis also improved urinary symptoms; lithotripsy for urinary stone also reduced menstrual symptoms (0.001<p<0.05). (d) In Gs+LCal, cholecystectomy or urinary lithotripsy did not improve urinary or biliary symptoms, respectively. Mechanisms of viscero-visceral hyperalgesia between organs with documented partially common sensory projection probably involve sensitization of viscero-viscero-somatic convergent neurons.
Article
Unlabelled: The aim of the study is to test if sustained nociceptive mechanical stimulation (SNMS) of latent myofascial trigger points (MTrPs) induces widespread mechanical hyperalgesia. SNMS was obtained by inserting and retaining an intramuscular electromyographic (EMG) needle within a latent MTrP or a nonMTrP in the finger extensor muscle for 8 minutes in 12 healthy subjects. Pain intensity (VAS) and referred pain area induced by SNMS were recorded. Pressure pain threshold (PPT) was measured immediately before and after, and 10-, 20-, and 30-minutes after SNMS at the midpoint of the contralateral tibialis anterior muscle. Surface and intramuscular EMG during SNMS were recorded. When compared to nonMTrPs, maximal VAS and the area under VAS curve (VASauc) were significantly higher and larger during SNMS of latent MTrPs (both, P < .05); there was a significant decrease in PPT 10 minutes, 20 minutes, and 30 minutes postSNMS of latent MTrPs (all, P < .05). Muscle cramps following SNMS of latent MTrPs were positively associated with VASauc (r = .72, P = .009) and referred pain area (r = .60, P = .03). Painful stimulation of latent MTrPs can initiate widespread central sensitization. Muscle cramps contribute to the induction of local and referred pain. Perspective: This study shows that MTrPs are one of the important peripheral pain generators and initiators for central sensitization. Therapeutic methods for decreasing the sensitivity and motor-unit excitability of MTrPs may prevent the development of muscle cramps and thus decrease local and referred pain.
Article
The aims of this study are to determine the frequency of fibromyalgia syndrome (FMS) in patients with chronic cervical myofascial pain (CMP) and to investigate the FMS characteristics in CMP patients. Ninty-three patients with CMP and 30 age-matched healthy women were included in this study. Main outcome measures included visual analog scale (VAS), Beck Depression Inventory (BDI), and pain pressure thresholds. CMP patients were evaluated for the existence of FMS. The severity of FMS was assessed with total myalgic score (TMS) and control point score (CPS). Most common clinical characteristics of FMS were noted. Of the 93 CMP subjects, 22 (23.6%) patients fulfilled the classification criteria for FMS. Number of tender points were higher (p=0.0), while TMS (p=0.0) and CPS (p=0.0) values were lower in comorbid CMP and FMS patients than regional CMP group. There were statistically significant differences between regional CMP patients and comorbid CMP and FMS patients regarding presence of fatigue (p=0.0) and irritable bowel syndrome (p=0.022). There was no statistically significant difference between patient groups regarding VAS values (p>0.05). BDI values of the regional CMP were significantly lower than comorbid CMP and FMS patients (p=0.011). In conclusion, we found that nearly a quarter of CMP patients were comorbid with FMS, and psychological and comorbid symptoms were more prominent in comorbid patients. We thought that, these two syndromes might be overlapping conditions and as a peripheral pain generator or inducer of central sensitisation, MPS might lead to FMS or precipitate and worsen the FMS symptoms.
Article
In this study; we aimed to compare the efficacy of local anesthetic injection and dry needling methods on pain, cervical range of motion (ROM), and depression in myofascial pain syndrome patients (MPS). This study was designed as a prospective randomized controlled study. Eighty patients (female 52/male 28) admitted to a physical medicine and rehabilitation outpatient clinic diagnosed as MPS were included in the study. Patients were randomly assigned into two groups. Group 1 (n = 40) received local anesthetic injection (2 ml lidocaine of 1%) and group 2 (n = 40) received dry injecting on trigger points. Both patient groups were given stretching exercises aimed at the trapezius muscle to be applied at home. Patients were evaluated according to pain, cervical ROM, and depression. Pain was assessed using Visual Analog Scale (VAS) and active cervical ROM was measured using goniometry. Beck Depression Inventory (BDI) was used to assess the level of depression. There were no statistically significant differences in the pre-treatment evaluation parameters of the patients. There were statistically significant improvements in VAS, cervical ROM, and BDI scores after 4 and 12 weeks in both groups compared to pre-treatment results (p < 0.05). No significant differences were observed between the groups (p > 0.05). Our study indicated that exercise associated with local anesthetic and dry needling injections were effective in decrease of pain level in MPS as well as increase of cervical ROM and decrease of depressive mood levels of individuals.
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
Recent studies have clarified the nature of myofascial trigger points (MTrPs). In an MTrP region, multiple hyperirritable loci can be found. The sensory components of the MTrP locus are sensitized nociceptors that are responsible for pain, referred pain, and local twitch responses. The motor components are dysfunctional endplates that are responsible for taut band formation as a result of excessive acetylcholine (ACh) leakage. The concentrations of pain- and inflammation-related substances are increased in the MTrP region. It has been hypothesized that excessive ACh release, sarcomere shortening, and release of sensitizing substances are three essential features that relate to one another in a positive feedback cycle. This MTrP circuit is the connection among spinal sensory (dorsal horn) neurons responsible for the MTrP phenomena. Recent studies suggest that measurement of biochemicals associated with pain and inflammation in the MTrP region, the sonographic study of MTrPs, and the magnetic resonance elastography for taut band image are potential tools for the diagnosis of MTrPs. Many methods have been used to treat myofascial pain, including laser therapy, shockwave therapy, and botulinum toxin type A injection.
Article
Myofascial pain syndrome (MPS), a regional pain condition caused by trigger points in muscle or muscle fascia, produces muscle pain, tenderness, and disability. The gold standard of treatment for MPS-infiltration of trigger points with anesthetic-may provoke discomfort to the patients and require medical intervention. This study was designed to compare the effects of a topical lidocaine patch, a placebo patch, and injection of anesthetic (infiltration) for the symptoms of MPS in terms of pain, disability, and local tissue hypersensitivity, and to determine the acceptability of the lidocaine patch to the patients. Patients were randomly allocated to receive 1 of 3 treatments: a lidocaine patch applied to the trigger point for 4 days (replacement every 12 hours; total daily dose, 350 mg), a placebo patch applied to the trigger point for 4 days (replacement every 12 hours), or infiltration of the trigger point with two 1-mL injections of 0.5% bupivacaine hydrochloride given 2 days apart. Treatment with the patches was double-blinded, whereas treatment with infiltration was single-blinded. The number of pain attacks, pain intensity at rest and on movement, and pain-related interference with daily activity, work activity, mood, and quality of life were recorded before, during, and after treatment using a visual analog scale (VAS). Pressure and electrical pain thresholds of the skin, subcutis, and muscle in the trigger point, target area, and a pain-free area were evaluated before starting therapy (day 1) and on days 5 and 9. A VAS was used to measure discomfort from therapy, and a diary was given to each patient to record requests for additional treatment (if needed) and adverse effects. Sixty white patients (46 women and 14 men) 19 to 76 years of age were studied. Mean (SD) age was 46.88 (15.37) years, and mean (SD) weight was 69.58 (13.94) kg. Twenty patients were assigned to each treatment group. Subjective symptoms did not change with placebo, but decreased significantly with the lidocaine patch and infiltration (both, P < 0.001) relative to baseline. Pain thresholds did not vary with the placebo patch, but increased significantly with the lidocaine patch and infiltration (all, P < 0.001); effects at muscle trigger points and target areas were greater with infiltration. Discomfort from therapy was greater with infiltration than with the lidocaine patch. Only patients in the placebo group requested additional treatment (P < 0.001). No adverse events occurred in any group. Lidocaine patches were effective in, and highly acceptable to, these patients with MPS and high tissue hypersensitivity.
Article
Trigger points are promoted as an important cause of musculoskeletal pain. There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points are conflicting. To systematically review the literature on the reliability of physical examination for the diagnosis of trigger points. MEDLINE, EMBASE, and other sources were searched for articles reporting the reliability of physical examination for trigger points. Included studies were evaluated for their quality and applicability, and reliability estimates were extracted and reported. Nine studies were eligible for inclusion. None satisfied all quality and applicability criteria. No study specifically reported reliability for the identification of the location of active trigger points in the muscles of symptomatic participants. Reliability estimates varied widely for each diagnostic sign, for each muscle, and across each study. Reliability estimates were generally higher for subjective signs such as tenderness (kappa range, 0.22-1.0) and pain reproduction (kappa range, 0.57-1.00), and lower for objective signs such as the taut band (kappa range, -0.08-0.75) and local twitch response (kappa range, -0.05-0.57). No study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. On the basis of the limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points. The reliability of trigger point diagnosis needs to be further investigated with studies of high quality that use current diagnostic criteria in clinically relevant patients.
Article
Trigger points associated with myofascial and visceral pains often lie within the areas of referred pain but many are located at a distance from them. Furthermore, brief, intense stimulation of trigger points frequently produces prolonged relief of pain. These properties of trigger points--their widespread distribution and the pain relief produced by stimulating them--resemble those of acupuncture points for the relief of pain. The purpose of this study was to determine the correlation between trigger points and acupuncture points for pain on the basis of two criteria: spatial distribution and the associated pain pattern. A remarkably high degree (71%) of correspondence was found. This close correlation suggests that trigger points and acupuncture points for pain, though discovered independently and labeled differently, represent the same phenomenon and can be explained in terms of the same underlying neural mechanisms. The mechanisms that play a role in the genesis of trigger points and possible underlying neural processes are discussed.
Article
This study tested whether two distinct thermographic patterns attributed to myofascial trigger points could distinguish between active and latent trigger points. A retrospective chart survey was undertaken with thermographic data divided into two groups: a) increased thermal emission only over the trigger point and b) over the area of pain referral. The criterion standard used in a blinded comparison was physical examination findings separating active from latent trigger points. All cases were drawn from a private practice referral center for thermographic evaluation of neck and low back injuries. A sample of 65 cases showing physical examination findings of trigger points was chosen from 229 consecutive motor vehicle accident case files. There was moderate agreement between the two methods of differentiating active from latent latent trigger points (Kappa = 0.44) with a specificity of 0.70 and a sensitivity of 0.74. When cases in which spinal segmental dysfunction were eliminated, the agreement increased (Kappa = 0.54) with specificity of 0.82 and sensitivity of 0.74. Thermography may be a useful tool in distinguishing active from latent trigger points, but the thermal imaging of spinal joint dysfunction may be a compounding factor.