Current studies on myofascial pain syndrome

A prospective clinical study to evaluate the comparative effectiveness of dry needling and laser therapy in neck and upper back myofascial pain syndrome

INTRODUCTION

Myofascial pain syndrome (MPS) is a disorder of the musculoskeletal system that is distinguished by the presence of pain, tenderness, muscle spasms, restricted joint range of motion, fatigue, and, in rare cases, autonomic dysfunction.

Assessment of the stiffness of the upper trapezius muscle in a group of asymptomatic people with cervical spine rotation asymmetry

This study investigated the relationship between the stiffness of the upper trapezius muscle and the range of rotational movement of the cervical spine. A total of 60 right-handed asymptomatic students participated in the study. Participants (N = 22) characterised by asymmetry in rotational movements were selected for the experimental group. A difference of ≥10° between right and left rotation of the cervical spine was considered asymmetrical. The control group (N = 38) included participants whose rotation difference was < 10°. Belonging to the experimental or control group did not significantly differentiate trapezius muscle stiffness. The rotation side differentiated the stiffness of the right and left trapezius muscles only in the group of people with rotational movement asymmetry. There were high correlation coefficients between right cervical rotation and the stiffness of the muscle on the right side, and between rotation to the left and the stiffness of the muscle on the left side. There is a relationship between the stiffness of the right and left upper trapezius muscles and the range of right and left rotational motion of the cervical spine. Stiffness of the upper trapezius correlates more strongly with rotation to the side on which the muscle lies than to the opposite side. Increased stiffness of the upper trapezius muscle on the side of limited cervical spine rotation is likely to be determined by the muscle fibre stretching mechanism.

A Bibliometric Analysis of Acupuncture Therapy in the Treatment of Musculoskeletal Pain from 2003 to 2022

Background

Acupuncture therapy has been widely used in the treatment of musculoskeletal pain (MP) in many countries around the world. However, there are no bibliometric studies on acupuncture therapy for MP. Therefore, the aim of this study was to analyze the current status, frontiers and hot spots in the use of acupuncture therapy for the treatment of MP.

Methods

Literature on acupuncture therapy for MP was extracted from the Web of Science Core Collection database from 2003 to 2022. CiteSpace 6.2.R4 (64-bit) software was used to analyze the number and centrality of journals, countries, institutions, authors, references and keywords, and the functions of co-occurrence and clustering were applied to draw a visual knowledge map.

Results

Over the past 20 years, the annual journal publications have been on a steady upward trend, with 438 articles published in 143 journals, including Acupuncture in Medicine Journal published the most (28, 6.39%), JAMA-Journal of the American Medical Association was the journal with the highest impact factor (IF = 120.7003), USA dominated with the most publications (140, 31.96%) among 44 countries, and among 196 research organizations Kyung Hee University was the most prolific (19, 4.34%) and Ha, In-Hyuk was the most published author (9, 2.05%). "Acupuncture" is the most popular and highly sought after keywords. "Low back pain" is the keyword with the highest centrality.

Conclusion

This article provides the current situation of the use of acupuncture therapy in the treatment of MP in the past 20 years, and statistical analysis reveals that "low back pain", "knit osteoporosis" and "break cancer" are new research diseases related to acupuncture therapy for MP, and "myobasic trigger point" is a new research direction of acupuncture therapy for MP. Therefore, this study helps researchers grasp the research hotspots and provide certain references for in-depth research and future topic selection.

Anatomical analysis of the intramuscular distribution patterns of the levator scapulae and the clinical implications for pain management

PURPOSE

The present study aimed to demonstrate the intramuscular nerve distribution of the levator scapulae muscle that is responsible for pain and to use this anatomic data to propose possible injection sites.

METHODS

Twenty levator scapulae muscles were dissected from 16 Korean embalmed cadavers. The intramuscular nerve distribution of the levator scapulae muscle was identified by whole-mount nerve staining to preserve and stain the nerve fibers without damage.

RESULTS

The posterior ramus of spinal nerves C3, C4, and C5 innervated the levator scapulae muscles. When the origin and insertion of the muscle were set to 0% and 100%, respectively, most of the intramuscular nerve terminals were located between 30 and 70%. This area may correspond to the cricoid cartilage of the sixth cervical vertebra.

CONCLUSION

Most intramuscular nerve terminals can be found in the middle and distal portions of the levator scapulae muscle. Our findings improve our understanding of the intramuscular nerve distribution of the levator scapulae muscle and will aid in pain management in clinical practice.

Research Trends of Acupuncture Therapy on Myofascial Pain Syndrome from 2000 to 2022: A Bibliometric Analysis

Background

Acupuncture has been widely used to relieve myofascial pain syndromes (MPS) in many countries. However, the bibliometric analysis of the global application of acupuncture for MPS remains unknown.

Purpose

The present study aims to evaluate the research trends and hot spots of acupuncture for MPS.

Methods

Literatures about acupuncture for MPS from 2000 to 2022 were obtained from the Web of Science. CiteSpace (6.1.R3) was used to analyze the number of publications, countries, institutions, authors, cited journals, cited authors, cited references and keywords.

Results

A total of 403 records were included in the final analysis. The total number of publications increased but with some fluctuations. The Pain was the most cited journals. The most productive country and institution were USA, and China Medicine University, respectively. Liwei Chou was the most prolific author, and Simons DG ranked first in the cited author. In the ranking of frequency and centrality in cited references, the first article was published by Tough EA and Simons DG, respectively. The keyword of "acupuncture" ranked first in frequency, "double blind" ranked first in centrality. "Meta-analysis" was the keyword with the strongest citation burst. There were three hot topics in this field, including "the clinical feature of MPS", "measure of intervention" and "research method". The mechanism of acupuncture on MPS was one of the main research directions.

Conclusion

This study reveals that acupuncture was more and more acceptable, while the cooperation between different countries, institutions and authors should be strengthened. The researches of therapeutic effect and mechanism were the main research directions. More high-quality clinical trials are needed to confirm the therapeutic effect of acupuncture for MPS, and more studies to unify the acupuncture parameters such as frequency, duration, and intensity. More basic studies are needed to elucidate the precise mechanism of acupuncture for MPS.

Dry needling for the treatment of acute myofascial pain syndrome in general practitioners' clinics: a cohort study

BACKGROUND

Musculoskeletal pain is one of the leading complaints in the ambulatory setting. There are many ways to treat it, including pharmacologic and non-pharmacologic approaches. Dry needling (DN) is an option that is easy to learn, cheap and has a good safety profile. The aim of this study was to assess the association between DN performed by GPs for acute myofascial pain syndrome (MPS) and pain relief and to evaluate factors associated with treatment success.

METHODS

In this prospective cohort study, two GPs performed DN in their clinics. Patients were asked to rank their pain using the Short-Form McGill Pain Questionnaire (SF-MPQ) before, 10-min and 1-week after the procedure. The SF-MPQ index consists of 3 parts; visual analog scale (VAS), pain rating index (PRI) and present pain intensity (PPI). Logistic regressions were performed to assess the variables associated with short- and medium- term success.

RESULTS

Fifty two patients were recruited from September 2019 until August 2020. VAS was 6.0 ± 2.3 (before), 4.1 ± 2.5 (10-min after) and 2.6 ± 2.71 (1-week after), P < 0.05. PRI was 17 ± 9.1 (before), 10.8 ± 8.5 (10-min after) and 5.1 ± 6.5 (1-week after), P < 0.05. PPI was 2.6 ± 1.0 (before), 1.7 ± 1.0 (10-min after) and 1.1 ± 1.2 (1-week after), P < 0.05. Short-term success was associated with the physician who performed the procedure (OR 10.08, 95% CI 1.15,88.4) and with the use of a single needle (vs. multiple needles inserted) (OR 4.55, 95% CI 1.03,20.11). Medium-term success was associated with being a native born (non-immigrant), OR 8.59, 95% CI 1.11,66.28 and with high level of initial pain, OR 11.22, 95% CI 1.82,69.27.

CONCLUSION

Our study demonstrated improvement in acute pain 10-min and 1-week after DN performed by a GP, in all parts of the SF-MPQ. Therefore, we believe DN is a good therapeutic option for GPs to aid patients suffering from MPS.

Effect of ischemic compression on myofascial pain syndrome: a systematic review and meta-analysis

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.

Assessing the efficacy and safety of Juan Bi Tang for dialysis-related myofascial pain in the fistula arm: Study protocol for a randomized cross-over trial

Background

Dialysis-related myofascial pain in hemodialysis (HD) patients is an important issue that is associated with many other psychosomatic problems. Effective interventions are required to alleviate pain in this group. Chinese herbal medicine (CHM) may be a potential therapeutic treatment for reducing pain. The aim of this study is to evaluate the effects of a classic CHM formula intervention on pain intensity, daily function, quality of life (QOL), and safety in patients receiving HD in a dialysis center within the context of southern Taiwan.

Methods

This will be a randomized, open label, cross-over trial with two parallel groups in a pre- and post-test study. Forty patients reporting myofascial pain related to the arteriovenous (AV) fistula in the arm during regular HD sessions will be recruited. Participants will receive 4 weeks of treatment with Juan Bi Tang (JBT) and 4 weeks of no treatment in a random order, separated by a washout period of 2 weeks. Treatment doses (3 g JBT) will be consumed thrice daily. The primary outcome measure will be the Kidney Disease Quality of Life 36-Item Short-Form Survey. Secondary outcomes will include the Fugl-Meyer Assessment-arm, Visual Analogue Scale (VAS) of pain, and grip strength. Outcomes will be collected before and after each intervention, for a total of four times per participant. The safety evaluation will focus on adverse events (AEs).

Discussion

This study will be the first to use CHM to treat patients receiving HD with dialysis-related myofascial pain in their fistula arm and to perform a complete assessment of the treatment, including records of QOL, arm function and muscle power, severity of pain, and safety. The results of the study will provide convincing evidence on the use of JBT as an adjuvant treatment for dialysis-related myofascial pain.

Trial registration

Clinicaltrials.gov registry (NCT04417101) registered 30 May 2020.

Trigger Point Injections

Myofascial pain and myofascial pain syndromes are among some of the most common acute and chronic pain conditions. Many interventional procedures can be performed in both an acute and chronic pain setting to address myofascial pain syndromes. Trigger point injections can be performed with or without imaging guidance such as fluoroscopy and ultrasound; however, the use of imaging in years past has been recommended to improve patient outcome and safety. Injections can be performed using no injectate (dry needling), or can involve the administration of local anesthetics, botulinum toxin, or corticosteroids.

The effect of one dry needling session on pain, central pain processing, muscle co-contraction and gait characteristics in patients with knee osteoarthritis: a randomized controlled trial

OBJECTIVES

To assess the immediate and three days postintervention effect of one dry needling session compared to one sham needling session on pain, central pain processing, muscle co-contraction and spatiotemporal parameters during gait in knee osteoarthritis patients.

METHODS

A double-blind randomized controlled trial was conducted. Sixty-one knee osteoarthritis patients were randomly assigned to the dry needling or sham needling group. Primary outcomes were pain and central pain processing. Secondary outcomes included muscle co-contraction and spatiotemporal parameters during gait. Patients were assessed at baseline and 15 min after the intervention, and pain also three days after the intervention. Linear mixed models were used to examine between- and within-group differences.

RESULTS

No significant between-group differences for pain were found, but within-group scores showed a significant decrease 15 min after sham needling and three days after dry needling. The mean conditioned pain modulation effect measured at the m. Trapezius worsened significantly 15 min after sham needling compared to after dry needling (between-group difference). However, individual conditioned pain modulation percentage scores remained stable over time. Various significant within-group differences were found 15 min after sham needling: a decrease of conditioned pain modulation measured at m. Quadriceps and m. Trapezius and stride- and step-time scores, and an increase in step length and widespread pain pressure threshold. A significant decrease in muscle co-contraction index of the m. Vastus Medialis and Semitendinosus was found as within-group difference 15 min after dry needling.

CONCLUSIONS

Dry needling has no larger effect on pain, central pain processing, muscle co-contraction and gait pattern 15 min and three days postintervention compared to sham needling. Mean conditioned pain modulation scores worsened after sham needling compared to after dry needling. Further research remains necessary.

A Biopsychosocial Model-Based Clinical Approach in Myofascial Pain Syndrome: A Narrative Review

One of the most common chronic musculoskeletal pain syndromes is myofascial pain syndrome (MPS). Trigger points (TrPs) are hypersensitive taut bands that appear in two genres, each with a different ratio in specific areas of the muscles, and when triggered, they can produce pain, numbness, and tingling. Various underlying causes (mechanical, nutritional, and psychological) have been discovered to participate in the pathogenesis of MPS, activating trigger points and intensifying the pain. Furthermore, genetic, social, and psychological factors seem to exacerbate these patients' clinical appearance, according to the biopsychosocial model, which seems to be closely linked to the formation of trigger points. Chronic pain and psychological distress frequently coexist, and psychological and social factors have been found to worsen the patient's quality of life and perpetuate the existing pain. The diagnosis is formed following a comprehensive physical and clinical examination, and the appropriate management technique is selected. For MPS treatment, management techniques based on the biopsychosocial model are used in conjunction with various myofascial release strategies and pharmacologic care. Exercise, posture correction, and a vitamin balance in the diet, especially in the Vitamin B complex, appear to prevent trigger point (TrP) activation. The precise etiology of MPS is not clear yet, and further research is needed to determine the root cause. A holistic approach, which blends the basic clinical care with the management of the biopsychosocial model, is essential to patients with MPS to regain their function and improve their quality of life and wellbeing.

Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review

Acupuncture and dry needling are both minimally invasive procedures that use thin, filiform needles without injectate for the management of a variety of neuromusculoskeletal pain conditions. While the theoretical constructs underlying the use of acupuncture and dry needling are unique, both appear to have the ability to elicit biochemical, biomechanical, endocrinological and neurovascular changes associated with reductions in pain and disability. However, optimal treatment dosage has yet to be determined, and there is a lack of consistency in the literature on the number of needles that should be inserted and the needle retention time. Therefore, the purpose of this narrative review is to further explore the importance of these two variables. While trigger point dry needling advocates single needle insertions via repetitive, quick in-and-out pistoning, most acupuncture and dry needling clinical trials have incorporated multiple needles for five to 40 min. Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.

Anatomical Study of the Innervation of the Masseter Muscle and Its Correlation with Myofascial Trigger Points

Background and Purpose

Myofascial pain syndrome (MPS) is widely prevalent in the general population; some reports estimate its prevalence ranges from 9 to 85%. Among the different locations where MPS may arise, pain related to the masseter muscle is referred as masticatory myofascial pain. MPS is characterized by myofascial trigger points (MTPs), which represent tender anatomical areas of a muscle where painful symptoms are elicited whenever stimulated. Previous publications have found MTPs to coincide with neuromuscular junctions at the motor end plate, at the innervation zone (IZ). Our study aimed to describe the innervation of the masseter muscle and relate it to clinically described myofascial trigger points (MTPs).

Materials and Methods

We mapped the nerve fiber distribution into the masseter muscles from 16 cadavers by anatomical dissection. We divided the muscle into six regions, three superior (I–III) and three inferior (IV–VI), and classified the nerve’s branches distribution according to these predetermined areas. Statistical analyses was made by Poisson distribution and logarithm link function followed by Bonferroni multiple comparisons (P<0.05).

Results

All six areas received branches from the masseteric nerve. Areas I and II (upper posterior and upper intermediate, respectively) had a significant higher number of nerve entries as compared to the remaining areas.

Conclusion

The penetration areas of the masseteric nerve have been established and MTPs are found in the innervation zones, clinicians should focus initially on the regions of the penetration points, for diagnostics and therapeutic measures, such as injections, dry needling and soft tissue interventions. Anatomical study of nerve supply to the masseter muscle can provide useful additional knowledge to further understanding masticatory myofascial pain and to direct therapeutic interventions and diagnostic studies of temporomandibular junction dysfunction.

Evaluation of the Combination of Muscle Energy Technique and Trigger Point Therapy in Asymptomatic Individuals with a Latent Trigger Point

(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.

Can we justify the continued use of botulinum toxin A in the management of myofascial pain?

We initially conducted a pilot study to evaluate the impact of botulinum toxin A (BtA) on increased masseteric mass associated with pain. After injection we assessed its impact on the muscle mass and the impact, if any, on reported pain, in a group of 10 patients who were refractory to conservative management. Results of this pilot study indicated that clenched and unclenched muscle dimensions showed no significant reduction (-0.82 clenched and -1mm unclenched). However, what did prove to be significant was an improvement in their pain scores as measured on a visual analogue scale (VAS). The mean VAS score before the injection was 8.2, and at six weeks after the injection it was 1.8. Following the pilot study we focused only on patients' pain scores. Our main study included 48 patients (81 muscles) who suffered with pain secondary to increased masseteric size, and had recorded their pain score out of 10 on the VAS before placement of BtA into each affected muscle and again six weeks after the injection. Results showed a mean pre-injection pain score of 7.9 and a mean post-injection pain score of 2.9. Following the results of this study on reported pain alone, our Trust has allowed funding to provide the intramuscular injection of BtA in appropriately selected patients.

Ultrasound-Guided Intermediate Cervical Plexus Block With Depot Steroids in the Management of Refractory Neck Pain Secondary to Cervicothoracic Myofascial Pain Syndrome: A Case Series

Persistent cervicothoracic myofascial pain is a common condition that causes loss of function and can result in significant health care costs. The underlying cause is tender trigger points that result in impaired muscle function. Standard treatment includes physiotherapy, medications, acupuncture, and trigger point injections. Patients who fail to respond have very limited treatment options. The authors present a novel treatment in 2 patients presenting with severe unilateral cervicothoracic myofascial neck pain that failed to respond to standard treatment. The novel treatment, ultrasound-guided intermediate cervical plexus block with depot steroids, produced significant and durable pain relief in the 2 patients.

Hyperexcitability to Electrical Stimulation and Accelerated Muscle Fatiguability of Taut Bands in Rats

Objective

Myofascial trigger points contribute significantly to musculoskeletal pain and motor dysfunction and may be associated with accelerated muscle fatiguability. The aim of this study was to investigate the electrically induced force and fatigue characteristics of muscle taut bands in rats.

Methods

Muscle taut bands were dissected out and subjected to trains of electrical stimulation. The electrical threshold intensity for muscle contraction and maximum contraction force (MCF), electrical intensity dependent fatigue and electrical frequency dependent fatigue characteristics were assessed in three different sessions (n=10 each) and compared with non-taut bands in the biceps femoris muscle.

Results

The threshold intensity for muscle contraction and MCF at the 10th, 15th and 20th intensity dependent fatigue stimuli of taut bands were significantly lower than those of non-taut bands (all p<0.05). The MCF at the 15th and 20th intensity dependent fatigue stimuli of taut bands were significantly lower than those at the 1st and 5th stimuli (all p<0.01). The MCF in the frequency dependent fatigue test was significantly higher and the stimulus frequency that induced MCF was significantly lower for taut bands than for non-taut bands (both p<0.01).

Conclusions

The present study demonstrates that the muscle taut band itself was more excitable to electrical stimulation and significantly less fatigue resistant than normal muscle fibres.

Comparing Trigger Point Dry Needling and Manual Pressure Technique for the Management of Myofascial Neck/Shoulder Pain: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to investigate short-term and long-term treatment effects of dry needling (DN) and manual pressure (MP) technique with the primary goal of determining if DN has better effects on disability, pain, and muscle characteristics in treating myofascial neck/shoulder pain in women.

METHODS

In this randomized clinical trial, 42 female office workers with myofascial neck/shoulder pain were randomly allocated to either a DN or MP group and received 4 treatments. They were evaluated with the Neck Disability Index, general numeric rating scale, pressure pain threshold, and muscle characteristics before and after treatment. For each outcome parameter, a linear mixed-model analysis was applied to reveal group-by-time interaction effects or main effects for the factor "time."

RESULTS

No significant differences were found between DN and MP. In both groups, significant improvement in the Neck Disability Index was observed after 4 treatments and 3 months (P < .001); the general numerical rating scale also significantly decreased after 3 months. After the 4-week treatment program, there was a significant improvement in pain pressure threshold, muscle elasticity, and stiffness.

CONCLUSION

Both treatment techniques lead to short-term and long-term treatment effects. Dry needling was found to be no more effective than MP in the treatment of myofascial neck/shoulder pain.

The Possible Role of Meditation in Myofascial Pain Syndrome: A New Hypothesis

BACKGROUND OF HYPOTHESIS

Myofascial pain syndrome (MPS) is the most common musculoskeletal pain disorder of the head and neck area. In the past, several theories were put forth to explain its origin and nature, but none proved complete. Myofascial pain responds to changing psychological states and stress, anxiety, lack of sleep, anger, depression and chronic pain are direct contributional factors. Myofascial pain syndrome may be considered as a psychosomatic disorder. There are numerous accepted palliative approaches, but of all, relaxation techniques stand out and initiate healing at the base level. In this article, the connection between mental factors, MPS and meditation are highlighted. Recent literature has shed light on the fundamental role of free radicals in the emergence of myofascial pain. The accumulating free radicals disrupt mitochondrial integrity and function, leading to sustenance and progression of MPS. Meditation on the other hand was shown to reduce free radical load and can result in clinical improvement. 'Mindfulness' is the working principle behind the effect of all meditations, and I emphasize that it can serve as a potential tool to reverse the neuro-architectural, neurobiological and cellular changes that occur in MPS.

CONCLUSIONS

The findings described in this paper were drawn from studies on myofascial pain, fibromyalgia, similar chronic pain models and most importantly from self experience (experimentation). Till date, no hypothesis is available connecting MPS and meditation. Mechanisms linking MPS and meditation were identified, and this paper can ignite novel research in this direction.

The local twitch response during trigger point dry needling: Is it necessary for successful outcomes?

BACKGROUND

Myofascial trigger point (MTrP) injection and trigger point dry needling (TrPDN) are widely accepted therapies for myofascial pain syndrome (MPS). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential.

OBJECTIVE

This is the first review exploring the available literature, regardless of study design, on the neurophysiological effects and clinical significance of the LTR as it relates to reductions in pain and disability secondary to MTrP needling.

METHODS

PubMed, MEDLINE, Science Direct and Google Scholar were searched up until October 2016 using terms related to trigger point needling and the LTR.

RESULTS

and Discussion: Several studies show that eliciting a LTR does not correlate with changes in pain and disability, and multiple systematic reviews have failed to conclude whether the LTR is relevant to the outcome of TrPDN. Post needling soreness is consistently reported in studies using repeated in and out needling to elicit LTRs and increases in proportion to the number of needle insertions. In contrast, needle winding without LTRs to MTrPs and connective tissue is well supported in the literature, as it is linked to anti-nociception and factors related to tissue repair and remodeling. Additionally, the positive biochemical changes in the MTrP after needling may simply be a wash out effect related to local vasodilation. While the LTR during TrPDN appears unnecessary for managing myofascial pain and unrelated to many of the positive effects of TrPDN, further investigation is required.

Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain

Purpose

To report the effects of combined onabotulinumtoxinA (Botox) injections and myofascial release physical therapy on myofascial pelvic pain (MFPP) by comparing pre- and posttreatment average pelvic pain scores, trigger points, and patient self-reported pelvic pain. Secondary outcomes were to examine posttreatment complications and determine demographic differences between patients with/without an improvement in pain.

Materials and Methods

This was an Institutional Review Board approved retrospective case series on women over 18 years with MFPP who received Botox and physical therapy between July 2006 and November 2014. Presence of trigger points and pelvic pain scores were determined by digital palpation of the iliococcygeus, puborectalis, obturator internus, and rectus muscles. Average pelvic pain scores (0–10) reflected an average of the scores obtained from palpation of each muscle. Self-reported improvement in pain was recorded as yes/no.

Results

Fifty women met the inclusion/exclusion criteria. Posttreatment, patients had lower average pelvic pain scores (3.7±4.0 vs. 6.4±1.8, p=0.005), and fewer trigger points (44% vs. 100%, p<0.001). Fifty-eight percent of patients (95% confidence interval, 44–72) noted an improvement in self-reported pain. Patients most likely to report no improvement in pain had chronic bowel disorders, while those most likely to report an improvement in pain had a history of past incontinence sling (p=0.03). Posttreatment complications included: constipation (8%), worsening urinary retention (2%), and urinary tract infection (4%).

Conclusions

Botox combined with soft tissue myofascial release physical therapy under anesthesia can be effective in treating women with chronic pelvic pain secondary to MFPP.

Comparative study of shock wave therapy and Laser therapy effect in elimination of symptoms among patients with myofascial pain syndrome in upper trapezius

BACKGROUND

The aim of this study is to compare the effects of laser therapy and shock wave therapy for symptoms treatment among patients with MPS in the upper trapezius muscle.

MATERIALS AND METHODS

In a clinical trial study, 46 patients were selected based on the clinical criteria and physiathrist diagnosis. Subjects were randomized into two groups as follows: Twenty individuals were assigned to exercise-medication-laser therapy group, and 26 to exercise-medication-shock wave therapy group. The pain was assessed based on visual analog scale (VAS), neck disability index (NDI), and SPADI in three stages: Before treatment, subsequently after treatment, and a month after treatment.

RESULTS

One man and 19 women, age group of 45.3 ± 7.7 years, were assigned into laser therapy group. Two men and 24 women, average age group of 42.3 ± 10.4 were assigned into shock wave therapy group. A significant difference was found among our study groups before treatment and after starting treatment for VAS, NDI, and SPDI indices, that is, two methods of treatments were effective (P < 0.001). However, among these two treatment methods, laser therapy provided higher effect on VAS and NDI as compared to the radial shock wave method (P < 0.05) in 2 weeks from starting the treatment (consequent to treatment).

CONCLUSION

According to this study results, we can conclude that shock wave and laser therapy results on similar effect in long-term for relieve of pain and eliminating symptoms in patients with myofascial but laser provides a faster optimal results.

Chronic Pain Management: An Overview of Taxonomy, Conditions Commonly Encountered, and Assessment

Chronic pain has multiple mechanisms that result in pain amplification and maintenance, including central and peripheral sensitization and altered modulation of pain perception. Assessment of pain requires comprehensive assessment of symptoms and signs, suspected pain mechanisms, and the patient's biopsychosocial context. Multiple validated measures exist for the assessment of pain symptoms, pain-related disability, psychological impact of pain, and candidacy for opioid management.

Dry Needling Related Short-Term Vasodilation in Chronic Sciatica under Infrared Thermovision

Vasomotor responses to dry needling (DN) of trigger points (TrPs) under infrared thermovision (IRT) camera control and TrPs coexistence in chronic sciatica patients have never been studied. Materials and Methods. Fifty consecutive chronic sciatica patients were enrolled in the study. DN under IRT control was performed for all patients regardless of gluteus minimus (GM) active TrPs examination. Then, the vasomotor response and its agreement with TrPs examination were evaluated. Results. The prevalence of GM active TrPs was 32%. DN provokes intensive vasodilatation for TrPs-positive patients only, with the localization dependent on referred pain during the procedure (r = 0.896;  P = 0.000) not the daily complaint. The increase of vasodilatation was, for example, for thigh, TrPs-positive +30.29% (P < 0.05) versus TrPs-negative +4.08%. Additionally, a significant skin temperature increase was observed for TrPs-positive only, for example, thigh +1.5 ± 1.3°C (maximum) and +1.2 ± 1.0°C (average) (both P < 0.05). Conclusion. GM active TrPs prevalence among chronic sciatica patients was around one in three. Every TrPs-positive subject presented with vasodilatation under IRT in the area of DN related referred pain. Although TrPs involvement in chronic sciatica patients is possible, further studies on a bigger group of patients are still required.

Myofascial trigger point therapy: laser therapy and dry needling

The aim of the present review is to discuss two forms of treatment for myofascial pain: laser therapy and dry needling. Although studies have reported the deactivation of myofascial trigger points with these two methods, clinical trials demonstrating their efficacy are scarce. The literature reports greater efficacy with the use of laser over dry needling. It has been suggested that improvements in microcirculation through the administration of laser therapy may favor the supply of oxygen to the cells under conditions of hypoxia and help remove the waste products of cell metabolism, thereby breaking the vicious cycle of pain, muscle spasm and further pain. While laser therapy is the method of choice for patients with a fear of needles and healthcare professionals inexperienced with the dry needling technique, further controlled studies are still needed to prove the greater efficacy of this method.

Physiologic effects of dry needling

During the past decades, worldwide clinical and scientific interest in dry needling (DN) therapy has grown exponentially. Various clinical effects have been credited to dry needling, but rigorous evidence about its potential physiological mechanisms of actions and effects is still lacking. Research identifying these exact mechanisms of dry needling action is sparse and studies performed in an acupuncture setting do not necessarily apply to DN. The studies of potential effects of DN are reviewed in reference to the different aspects involved in the pathophysiology of myofascial triggerpoints: the taut band, local ischemia and hypoxia, peripheral and central sensitization. This article aims to provide the physiotherapist with a greater understanding of the contemporary data available: what effects could be attributed to dry needling and what are their potential underlying mechanisms of action, and also indicate some directions at which future research could be aimed to fill current voids.

Exploring the central modulation hypothesis: do ancient memory mechanisms underlie the pathophysiology of trigger points?

A myofascial trigger point (TrP) is a point of focal tenderness, associated with a taut band of muscle fibers, that can develop in any skeletal muscle. TrPs are a common source of pain and motor dysfunction in humans and other vertebrates. There is no universally accepted pathophysiology to explain the etiology, symptomatology and treatment of TrPs. This article reviews and extends the author's previously published hypothesis for the pathophysiology of TrPs, "Trigger Points and Central Modulation-A New Hypothesis." The author proposes that central nervous system-maintained global changes in α-motoneuron function, resulting from sustained plateau depolarization, rather than a local dysfunction of the motor endplate, underlie the pathogenesis of TrPs.

Effects of far-infrared irradiation on myofascial neck pain: a randomized, double-blind, placebo-controlled pilot study

OBJECTIVES

The objective of this study was to determine the relative efficacy of irradiation using a device containing a far-infrared emitting ceramic powder (cFIR) for the management of chronic myofascial neck pain compared with a control treatment.

DESIGN

This was a randomized, double-blind, placebo-controlled pilot study.

PARTICIPANTS

The study comprised 48 patients with chronic, myofascial neck pain.

INTERVENTION

Patients were randomly assigned to the experimental group or the control (sham-treatment) group. The patients in the experimental group wore a cFIR neck device for 1 week, and the control group wore an inert neck device for 1 week.

MAIN OUTCOME MEASUREMENT

Quantitative measurements based on a visual analogue scale (VAS) scoring of pain, a sleep quality assessment, pressure-pain threshold (PPT) testing, muscle tone and compliance analysis, and skin temperature analysis were obtained.

RESULTS

Both the experimental and control groups demonstrated significant improvement in pain scores. However, no statistically significant difference in the pain scores was observed between the experimental and control groups. Significant decreases in muscle stiffness in the upper regions of the trapezius muscles were reported in the experimental group after 1 week of treatment.

CONCLUSIONS

Short-term treatment using the cFIR neck device partly reduced muscle stiffness. Although the differences in the VAS and PPT scores for the experimental and control groups were not statistically significant, the improvement in muscle stiffness in the experimental group warrants further investigation of the long-term effects of cFIR treatment for pain management.

Myofascial trigger points and innervation zone locations in upper trapezius muscles

Background

Myofascial trigger points (MTrPs) are hyperirritable spots located in taut bands of muscle fibres. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Thus, it is suggested that MTrPs will be overlap the innervation zone (IZ). The purpose of this work was to describe the location of MTrPs and the IZ in the right upper trapezius.

Methods

We screened 71 individuals and eventually enrolled 24 subjects with neck pain and active MTrPs and 24 neck pain-free subjects with latent MTrPs. Surface electromyography (sEMG) signals were detected using an electrode matrix during isometric contraction of the upper trapezius. A physiotherapist subsequently examined the subject’s trapezius to confirm the presence of MTrPs and establish their location. IZ locations were identified by visual analysis of sEMG signals. IZ and MTrPs locations were described using an anatomical coordinate system (ACS), with the skin area covered by the matrix divided into four quadrants.

Results

No significant difference was observed between active and latent MTrPs locations (P = 0.6). Forty-five MTrPs were in the third quadrant of the ACS, and 3 were included in second quadrant. IZs were located approximately midway between the seventh cervical vertebrae and the acromial angle in a limited area in the second and third quadrants. The mean distance between MTrP and IZ was 10.4 ± 5.8 mm.

Conclusions

According to the acquired results, we conclude that IZ and MTrPs are located in well-defined areas in upper trapezius muscle. Moreover, MTrPs in upper trapezius are proximally located to the IZ but not overlapped.

Probable mechanisms of needling therapies for myofascial pain control

Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically. MTrP is defined as the hyperirritable spot in a palpable taut band of skeletal muscle fibers. Appropriate treatment to MTrPs can effectively relieve the clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS patients with dry needling based on the Traditional Chinese Medicine (TCM) theory. The possible mechanism of AcP analgesia were studied and published in recent decades. The analgesic effect of AcP is hypothesized to be related to immune, hormonal, and nervous systems. Compared to slow-acting hormonal system, nervous system acts in a faster manner. Given these complexities, AcP analgesia cannot be explained by any single mechanism. There are several principles for selection of acupoints based on the TCM principles: “Ah-Shi” point, proximal or remote acupoints on the meridian, and extra-meridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and discussed.

Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study

We prospectively analysed the outcome after botulinum injection in patients who did not recover after conservative measures to manage masticatory myofascial pain, and who were not willing to take low dose tricyclic antidepressants as a muscle relaxant. We prospectively 62 patients were assessed with visual analogue scores (VAS) for pain on the affected side before, and 6 weeks after botulinum injection(s) (50 units Dysport in up to 3 sites), and measured mouth opening in mm. Of those treated 49 (79%) showed at least some improvement (pain reduced by more than 25%). Patients reported more than a 90% reduction in the VAS for 25 (30%) of the 84 sides of the face treated. Only 22 of the 62 patients had more than one course of treatment to the same side. Interincisal distance improved by a mean/median of 0.9 mm (p<0.03) after treatment. Side effects included 3 cases of temporary weakness of a facial muscle. Ranking the VAS pain scores using the Wilcoxon test before and after injection showed a significant reduction in pain (median change -29.5, interquartile range -53 to -16, p<0.0001). The treatment significantly improved patients' pain scores and the overall mean/median reduction in pain was 57%. Botulinum injection does not guarantee complete resolution of myofascial pain, but it usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed.

Endometriosis and abdominal myofascial pain in adults and adolescents

Endometriosis and myofascial pain are common disorders with significant impact on quality of life. Increasingly, these conditions are being recognized as highly interconnected through processes that have been described for more than a century. This review is directed to this interconnection through a description of the relationships of endometriosis to proposed mechanisms of pain and chronic pain physiology; the clinical assessment of myofascial representations of this pain; and an approach to the management of these interconnected disorders.

Myofascial pain syndromes and their evaluation

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.

Correlation of splint therapy outcome with the electromyography of masticatory muscles in temporomandibular disorder with myofascial pain

OBJECTIVES

The aim of this study was to assess the effect of occlusal splint therapy on the electromyographic amplitude records (μV) of masticatory muscles in temporomandibular disorder (TMD) with myofascial pain and to detect a possible existence of a relationship between this effect and the treatment outcome.

MATERIALS AND METHODS

Forty patients (23 females and 17 males) having TMD with myofascial pain were included in this study. They were randomly divided into two equal groups (20 of each). The first group (A) was treated by occlusal splints for 6 months while the second group (B) acted as a control. A clinical assessment and surface electromyography (EMG) for the masticatory muscles were performed at the beginning of the study, then 6 months later. The collected data were statistically analyzed using paired t-test. The differences were considered significant at p < 0.05.

RESULTS

The results showed that 85% of group A either completely recovered (35%) or clinically improved (50%) while only 20% of group B had a spontaneous improvement. In group A, the means of the electromyographic amplitude records (μV) of the monitored muscles have decreased after 6 months. However, the decrease was statistically insignificant (p > 0.05) in the patients (15%) who had no clinical changes. In group B, the means of the muscles' records (μV) in the left side slightly increased while those of the right side slightly decreased. These changes were statistically insignificant (p > 0.05).

CONCLUSIONS

Occlusal splint could eliminate or improve the signs and symptoms of TMD patients with myofascial pain. It reduces the electromyographic amplitude records (μV) of the masticatory muscles. The splint therapy outcome has a correlation with the electromyographic amplitude changes of the masticatory muscles.

Myofascial trigger points: spontaneous electrical activity and its consequences for pain induction and propagation

Active myofascial trigger points are one of the major peripheral pain generators for regional and generalized musculoskeletal pain conditions. Myofascial trigger points are also the targets for acupuncture and/or dry needling therapies. Recent evidence in the understanding of the pathophysiology of myofascial trigger points supports The Integrated Hypothesis for the trigger point formation; however unanswered questions remain. Current evidence shows that spontaneous electrical activity at myofascial trigger point originates from the extrafusal motor endplate. The spontaneous electrical activity represents focal muscle fiber contraction and/or muscle cramp potentials depending on trigger point sensitivity. Local pain and tenderness at myofascial trigger points are largely due to nociceptor sensitization with a lesser contribution from non-nociceptor sensitization. Nociceptor and non-nociceptor sensitization at myofascial trigger points may be part of the process of muscle ischemia associated with sustained focal muscle contraction and/or muscle cramps. Referred pain is dependent on the sensitivity of myofascial trigger points. Active myofascial trigger points may play an important role in the transition from localized pain to generalized pain conditions via the enhanced central sensitization, decreased descending inhibition and dysfunctional motor control strategy.

Dysport® for the treatment of myofascial back pain: Results from an open-label, Phase II, randomized, multicenter, dose-ranging study

Background and purpose Botulinum toxin type A (BoNT-A) has antinociceptive and muscle-relaxant properties. The objectives of this study were to investigate the efficacy and safety of a single BoNT-A (Dysport®) treatment in myofascial back pain. Methods In this randomized, open-label, multicenter study, adults with myofascial lower back pain received Dysport® injections at four trigger points (60,80 or 120 units per injection point). Patients were followed for 12 weeks. The a priori primary endpoint was a pooled evaluation, at Week 6, of seven measures of efficacy, including pain intensity (patient diary), modified Pain Disability Index (PDI) score, use of interfering concomitant analgesics, and patient-rated global efficacy. Optional assessments of pressure thresholds and tissue compliance were conducted. Safety was also assessed. Results A total of 202 patients were randomized to treatment and 189 patients received a low (n = 57), medium (n = 57), or high (n = 75) total dose of Dysport® at 34 centers in Germany between October 2002 and October 2003. All treated patients were included in the safety population; 8 patients were excluded from the intention-to-treat population. Patients had moderate to severe pain at baseline. At baseline, 120 patients were receiving concomitant analgesic therapy; 6.7%, 74.2% and 19.2% were considered to cause mild, moderate and severe interference with pain measurements, respectively. There was no difference between doses for the a priori combined primary endpoint. Patient-reported pain intensity scores at rest and on movement decreased significantly after treatment for all groups combined (p < 0.0001 at all visits). At Week 6, reductions in pain intensity at rest were 29%, 19% and 26% for the low-, medium- and high-dose groups, respectively; reductions in pain intensity on movement were 27%, 18% and 26%, respectively. Overall, patients who reported pain intensity reductions at Week 6 were evident within 3 weeks of treatment and were maintained for the 12 weeks of the study. In the total population, significant decreases in mean PDI sum scores from baseline were observed from Week 3 and were maintained through to the end of treatment (Week 12); no differences between the dose groups were observed. Pressure thresholds and tissue compliance also increased during the study. Adverse events were generally as expected for BoNT-A; the majority were mild or moderate in severity. Conclusions Dysport® treatment was associated with reductions in myofascial back pain and was well tolerated. Nodose-response relationship was observed; treatment with Dysport® using a four-trigger-point injection protocol at 60 units per trigger point was associated with a clinically relevant and statistically significant improvement in pain and pain-related disability; there was no additional benefit from the higher doses. Implications Our findings are limited by the lack of a control group and further research is warranted to confirm the value of Dysport® for the treatment of myofascial back pain and confirm the optimum dosing in this indication.