Improvement in clinical outcomes after dry needling versus myofascial release on pain pressure thresholds, quality of life, fatigue, pain intensity, quality of sleep, anxiety, and depression in patients with fibromyalgia syndrome

Alternative therapies in chronic non-cancer pain management: A scoping review of randomized controlled trials

BACKGROUND

Chronic pain is one of the most challenging health problems in modern society, placing significant burdens on individuals and healthcare systems. While pharmacological treatments remain the primary approach to pain management, their limitations often restrict choices for both clinicians and patients. In contrast, complementary therapies are gaining recognition for their potential effectiveness and safety. However, the current literature lacks a comprehensive summary of the role of complementary therapies in chronic pain management.

OBJECTIVE

This review aims to summarize the complementary therapies used in chronic non-cancer pain management, assess their practical applications, identify research gaps and limitations, and provide a comprehensive perspective for the development of chronic non-cancer pain management and personalized pain management strategies.

METHODS

This scoping review followed the PRISMA-ScR guidelines. Randomized controlled trials (RCTs) published in the last decade were retrieved from PubMed and Web of Science using the keywords "chronic pain" and "complementary therapy." Non-English studies were excluded.

RESULTS

A total of 848 RCTs were identified, of which 128 met the inclusion criteria. The included studies addressed chronic musculoskeletal pain (102 studies), chronic visceral pain (5 studies), chronic neuropathic pain (7 studies), and 13 studies that did not specify the pain type. The complementary therapies investigated included acupuncture, manual therapy, exercise therapy, psychological interventions, mind-body therapies, and physical modalities.

CONCLUSION

This review provides preliminary evidence supporting the efficacy and safety of complementary therapies in the management of chronic non-cancer pain. However, methodological and quality-related limitations were identified in the included studies. Future high-quality RCTs are needed to validate the long-term efficacy of these therapies, explore their mechanisms of action, and provide stronger evidence for their clinical application.

REGISTRATION

This scoping review is registered on the Open Science Framework (OSF) under the following DOI: https://doi.org/10.17605/OSF.IO/67K32.

Dry needling in people with fibromyalgia: A randomized controlled trial of its effects on pain sensitivity and pain catastrophizing influence

BACKGROUND

Dry needling (DN) has been demonstrated as an effective treatment for patients with fibromyalgia (FM). It is crucial to take into consideration catastrophizing, a psychological construct that could potentially undermine the short-term efficacy of DN.

OBJECTIVE

To analyze the effects of DN in the infraspinatus muscle on both local and remote pressure pain thresholds (PPTs) and its relationship with baseline levels of pain catastrophizing in patients with FM.

DESIGN

Randomized controlled trial.

METHODS

All participants were randomly assigned to one of three interventions: DN, sham DN, and no intervention. Hong's fast-in and fast-out technique was implemented during the DN intervention.

MAIN OUTCOMES MEASURES

The primary study outcome pain sensitivity (local and remote PPTs) was assessed at baseline, immediately post, and 24 h post intervention to evaluate short-term effect. Pain catastrophizing was measured at baseline in all participants using the Pain Catastrophizing Scale. To analyze the effect of DN on local and remote PPTs, an analysis of covariance was performed using catastrophism as covariate. Additionally, to examine the possible influence of catastrophism on local PPTs ratings in the subsequent assessment we performed a moderation analysis.

PATIENTS

A total of 120 women diagnosed with FM. However, during the follow-up period, 24 participants discontinued their involvement, leaving a final cohort of 96 patients who successfully concluded the study.

RESULTS

DN showed significant differences in both local PPTs immediately post intervention and 24 h post intervention (MD [95% confidence interval] = 3.21 [0.40-6.02] kg/cm2, p = .019; and 2.84 [0.10-5.58] kg/cm2, p = .039, respectively) compared to sham and no-intervention groups. In addition, DN group results suggest that moderate values of catastrophizing (<35) diminish the effect of DN immediately postintervention.

CONCLUSIONS

The infraspinatus DN led to a notable reduction in local PPTs among individuals with FM. Additionally, the effectiveness of the DN treatment was influenced by pain catastrophizing.

Anatomical landmarks and procedure technique of Levator Scapulae Plane Block (LeSP block): Case report: Ultrasound-guided block of the superficial, deep and distal planes of the levator scapulae muscle for treatment of shoulder girdle myofascial pain

Neck pain is a prevalent issue associated with musculoskeletal disorders. This study describes the interfascial Levator Scapulae Plane Block (LeSP Block) technique, using ultrasound guidance for local anesthetic administration to treat chronic neck pain. Two patients, 1 77-year-old female and 1 50-year-old female, underwent the LeSP Block. Immediate postprocedure pain relief was achieved in both, with 1 patient experiencing complete pain remission (VAS = 0) and the other showing significant improvement (VAS = 2) after 30 days. The LeSP Block demonstrated effectiveness and ease of use, suggesting its inclusion in pain management strategies for shoulder girdle and scapular pain. Further anatomical studies aimed at improving the anatomical description of the accessory spinal nerve are recommended to refine the technique.

Biomechanical Profile after Dry Needling in Mixed Martial Arts

The purpose of this study was to compare the effects of dry needling (DN) intervention on the responses of muscle tone, stiffness, and elasticity, as well as power, pressure pain thresholds, and blood perfusion of the flexor carpi radialis muscle in mixed martial arts (MMA) athletes. Thirty-two trained/developmental men MMA fighters (25.5±4.5 years; 24.5±3 body mass index) participated in a randomized crossover study. Participants underwent a single intervention, receiving both DN and placebo. Laser Doppler flowmetry measured blood perfusion, while a myotonometer assessed the mechanical characteristics of muscle tone, stiffness, and elasticity of the flexor carpi radialis muscle. Pressure pain thresholds (PPT) were measured using an algometer, and maximal forearm muscle force was measured using a hand dynamometer. Outcomes were assessed at baseline, immediately after, and 24 hours and 48 hours post-intervention. A two-way repeated-measures ANOVA revealed significant Intervention*Time interaction for all outcomes: perfusion unit (p<0.001), muscle tone (p<0.001), stiffness (p<0.001), elasticity (p<0.001), PPT (p<0.001) and maximal forearm muscle force (p<0.001). The current study suggests that a single session of DN enhances muscle recovery, increases muscle strength, and improved PPT in MMA athletes. These positive adaptations appear to last up to 48 hours in some variables.

Manual therapy and dry needling improve mobility, pain and reduce fear of COVID-19 in temporomandibular disorder patients: Randomized controlled trial

BACKGROUND AND PURPOSE

The COVID-19 pandemic exacerbated pain and joint mobility outcomes in patients with temporomandibular disorders (TMD), being that effective treatments are of clinical interest. We aimed to evaluate the effects of manual therapy (MT) and dry needling (DN), compared to cognitive-behavioral therapy/control (CO), on pain, articular mobility, and fear of COVID-19 in patients with TMD.

MATERIALS AND METHODS

Sixty participants with myofascial TMD were randomly assigned to three groups: MT, DN, and CO. Participants received four weeks of treatment (30 min per week). The participants completed the Fear of COVID- 19 Scale, the Visual Analog Scale, and mandibular mobility was assessed. Data were collected before the intervention (T1), after the last treatment session (T2), and 30 days after the end of treatment (T3). The data were analyzed using two-way Mixed-Design ANOVA, considering the group effect (DN x MT x CO), time (T1, T2, and T3), and the interaction time × group in the observed variance of outcomes.

RESULTS

We observed an interaction effect of time × group for maximum mouth opening, protrusion, and pain. The maximum mouth opening increased in the DN and MT groups (p = 0.005), while protrusion increased in the DN group (p = 0.007; test power = 97%, large effect size). A decrease in pain scores over time was observed in the DN and MT groups (p < 0.001; test power>99%, large effect size). The fear of COVID-19 score decreased in the DN and MT groups after 30 days (p = 0.033).

CONCLUSION

DN and MT improve pain, joint mobility, and fear of COVID-19 in patients with TMD.

A Review of the Application of Myofascial Release Therapy in the Treatment of Diseases

Myofascial release (MFR) therapy is widely used in clinical practice to treat various musculoskeletal and pain-related conditions. However, there is a lack of comprehensive reviews that systematically evaluate its effectiveness across different medical conditions, leading to inconsistent applications and understanding of its therapeutic potential. This review aims to synthesize the current applications of myofascial release therapy in the treatment of various diseases, highlighting its efficacy and identifying areas where further research is needed. The review covers the application of myofascial release therapy in conditions such as chronic pain, fibromyalgia, post-surgical recovery, and neurological disorders. It evaluates the outcomes of existing studies, identifies gaps in the literature, and discusses the mechanisms through which myofascial release exerts its effects. Additionally, the review provides insights into the limitations of current research and suggests directions for future studies to enhance the clinical application of myofascial release therapy.

The effect of myofascial release of the physiological chains on the pain and health status in patients with fibromyalgia, compared to passive muscle stretching and a control group: a randomized controlled clinical trial

OBJECTIVE

To explore the potential effectiveness of myofascial release compared to passive muscle stretching and to a control group in modulating pain intensity and health status in adults diagnosed with fibromyalgia (FM).

MATERIALS AND METHODS

A preliminary randomized controlled clinical trial was conducted, consisting of eight weekly sessions. The participants were divided into three groups: myofascial release group (RG = 13), a muscle stretching group (SG = 13), and a control group (CG = 12), which received advice from a rheumatologist. The outcomes measured were the visual analogue pain scale (VAS), the fibromyalgia impact questionnaire (FIQ) (representing health status), and the number of painful areas. Univariate analyzes of covariance (ANCOVA) were performed at baseline, after 4 weeks (during treatment), after 8 weeks (post-treatment), and after 12 weeks (follow-up). The International Physical Activity Questionnaire (IPAQ), the Beck Depression Inventory (BDI) and the Pain Catastrophizing Scale (PCS) were included as covariates. Clinical trial registration number: NCT: 03408496.

RESULTS

After eight weeks, the RG showed lower VAS scores compared to the CG (mean difference 95% CI: -5.10 to -1.26) and the SG (mean difference 95% CI: -4.9 to -0.23) with no difference between the SG and the CG. The total FIQ score for the RG was lower than the CG after 4 weeks (95% CI: -49.92 to -5.61), and 8 weeks (mean difference 95% CI: -52.72 to -15.73), although there was no difference between the RG and SG, as well as between the SG and CG, at both time points. The number of painful body areas was similar in all groups at the four time points.

CONCLUSION

Preliminary results suggest that the RG possibly showed greater improvements in pain intensity and health status compared to the CG, and possibly greater improvements in pain intensity compared to the SG.

Effectiveness of manual lymphatic drainage in women with fibromyalgia: A pilot study

BACKGROUND

Currently there is no treatment capable of significantly alleviating all the symptoms of fibromyalgia (FM), even though it is a complex syndrome with a high prevalence in the population.

DESIGN

Experimental study using a single-blind, randomised, clinical trial.

OBJECTIVE

To analyse the efficacy of manual lymphatic drainage (MLD) as an alternative to traditional treatment of fibromyalgia (FM) in women.

METHODS

This was an experimental study using a single-blind, randomised, clinical trial of 20 women between 30 and 55 years old with FM. Patients were divided into an experimental group (n = 10) and a control group (n = 10). During the study, 3 measurements of pain (visual analogue scale and algometry), FM impact (Fibromyalgia Impact Questionnaire), sleep quality (Index Pittsburgh), anxiety and depression (Hospital Anxiety and Depression Scale) were recorded. Treatment of the experimental group consisted of 2 weekly MLD sessions for 6 weeks.

RESULTS

The effect of the interaction of MLD showed statistically significant results in Right intercostal space (F2,36 = 3.54; p = 0.04; n2p = 0.16). The sleep quality was significantly better favour of the treatment (F2,36 = 4.16; p = 0.01; n2p = 0.20).

CONCLUSIONS

MLD therapy demonstrated effects in the experimental group in contrast to the control group across the intervention period concerning the right intercostal space and sleep-related factors. However, MLD did not result in observable alterations in pain perception.

Electrical dry needling versus a non-invasive multicomponent intervention in the treatment of myofascial trigger points in patients with chronic low back pain: A randomised clinical trial

OBJECTIVE

To compare the effects of electrical dry needling with a non-invasive multi-component intervention in patients with chronic low back pain.

DESIGN

A randomised single-blind clinical trial.

SETTING

Outpatient Physiotherapy Clinic; home.

PARTICIPANTS

Sixty-four patients with chronic low back pain aged 30-65 years.

INTERVENTIONS

Six-week electrical dry needling on myofascial trigger points, and a non-invasive multicomponent intervention (home exercise programme, stretching and ischemic compression).

MAIN MEASURES

Pain (Visual Analogue Scale), disability (Roland-Morris Disability Questionnaire and Oswestry Disability Index), kinesiophobia (Tampa Scale of Kinesiophobia), quality of life and sleep (Short Form 36-item Health Survey and Pittsburgh Sleep Quality Index), isometric endurance of trunk flexor muscles (McQuade test), lumbar mobility in flexion (finger-to-floor distance), and pressure pain threshold (algometer) were assessed at baseline, after 6 weeks, and after 2 months.

RESULTS

ANOVA showed statistically significant differences in group-by-time interaction for most pain pressure thresholds of myofascial trigger points (P < 0.05), for disability (Roland-Morris Disability Questionnaire: F = 6.14, P = 0.016; and Oswestry Disability Index: F = 7.36, P = 0.009), for trunk anteflexion (F = 10.03, P = 0.002) and for habitual sleep efficacy (F = 6.65, P = 0.012), use of hypnotics (F = 4.77, P = 0.033) and total score of quality of sleep (F = 8.23, P = 0.006).

CONCLUSIONS

In comparison to a non-invasive multicomponent intervention, electrical dry needling has more positive effects on disability, pain intensity, kinesiophobia, and reducing patients' sensitivity to myofascial trigger points pressure, at post-treatment and at 2 months.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04804228. Registered on May 28th, 2021. Available at https://clinicaltrials.gov/ct2/show/NCT04804228.

Meta-epidemiologic review: blinding and sham treatment in clinical trial design for osteopathic manipulative treatment research

Objective

To analyze the consistency of study designs in osteopathic manipulative treatment (OMT) research, focusing on blinding protocols and the use of sham treatments.

Data Source and Study Selection

PubMed and CINAHL were searched in January 2022. A total of 83 research studies between 2009 and 2021 were selected based on the presence of a double- or single-blind study design and/or sham treatment.

Data Extraction and Analysis

Data regarding the primary outcome measures, blinding design, measures used to determine success of blinding, osteopathic technique used, and sham technique used for each eligible study were extracted and compared among different study designs.

Results

A total of 5968 subjects participated in the 83 trials. The study population mainly consisted of asymptomatic individuals (25%) and chronic back pain patients (19%). Light touch was employed most commonly (49%) as the sham treatment, followed by unrelated sham (20%) and incomplete maneuvers (20%). Most studies blinded the subjects (80%) or the outcome evaluator/data analyzer (71%), while only 20% studies blinded the osteopathic physicians.

Conclusions

Strict double-blinding is achievable for OMT clinical research by blinding the subjects and data collectors/analyzers rather than the osteopaths providing the actual treatment. The use of questionnaires to determine the success of blinding should be considered. Additionally, including OMT-naïve subjects is preferred to enhance blinding success. When designing a sham treatment, careful consideration should be given to blinding the data collector, accounting for the placebo effect, and incorporating an additional no-treatment control group to improve the rigor of the study design.

Effects of progressive intensity resistance training on the impact of fibromyalgia: protocol for a blinded randomized controlled trial

BACKGROUND

Fibromyalgia guidelines indicate that exercise is critical in the management of fibromyalgia, and there is evidence that patients with fibromyalgia can perform resistance training at moderate and high intensities. However, despite the biological plausibility that progression of intensity provides greater benefit to individuals, no studies have compared different intensities (progressive versus constant intensities) of the same exercise in this population.

OBJECTIVE

To compare the effect of 24 sessions of resistance training (progressive vs. constant intensity) on impact of fibromyalgia, sleep quality, anxiety, depression, pain, walking ability, and musculoskeletal capacity.

METHODS

A protocol for a blinded randomized controlled trial. The sample will be randomized into three groups: group 1 (progressive intensity, experimental), group 2 (constant intensity, control A), and group 3 (walking, control B). Group 1 will perform resistance training at moderate intensity (50% of maximum dynamic strength), previously determined by the 1 repetition maximum (1-RM) test in the proposed exercises. The strength of each individual will be reassessed every 4 weeks (by 1-RM) and the intensity of each exercise will be positively adjusted by 20% of the value observed in kg (i.e., first month 50%; second month 70%; third month 90% of the maximum dynamic strength). Group 2 will perform the same procedure, but the intensity will be maintained at 50% of the maximum dynamic strength throughout the treatment (i.e., constant intensity from the first to the third month). Group 3 will perform a 40-minute treadmill walk at low intensity, defined by a walking speed corresponding to 60-70% of the maximum heart rate, which we will control with a heart rate monitor. All groups will receive a 45-minute pain education session prior to the exercise program, covering the pathophysiologic mechanisms of chronic pain, strategies for coping with pain, avoiding hypervigilance, and deconstructing beliefs and myths about chronic pain.

DISCUSSION

The results of the present study may help health care professionals adjust the intensity of resistance training and thus plan the most effective intervention (progressive or constant intensity) to reduce the impact of fibromyalgia on patients' lives.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9pbq9fg, date of registration: October 06, 2022.

Acute outcomes of acupuncture and dry needling over peripheral acute fatigue in untrained healthy volunteers: A randomized controlled clinical trial

Peripheral acute fatigue (PAF) is defined as when the skeletal muscle is incapable of generating power. We aimed to investigate the acute effects of traditional Chinese acupuncture (TCA) and dry needling (DN) over PAF induced on the biceps brachii of untrained healthy volunteers. We conducted a randomized, single-blind controlled clinical trial. All volunteers (n = 45) underwent fatigue induction protocols repeated before and after treatment with TCA (TCA group; TCAg; n = 15), DN (DN group; DNg; n = 15), and rest (control group; Cg; n = 15). Assessments of PAF, skin temperature, and exercise time occur before and after each event: 1st fatigue induction (FI), treatment, and 2nd FI. We used repeated measures ANOVA adjusted with Bonferroni post hoc test to determine any change in tested variables (PAF-VAS, PAF-EMG, and skin temperature) at different time points compared to the baseline. Paired Samples t-test was used for the variable exercise times. All statistical tests considered' the significance level at p ≤ 0,05. There was no difference between groups in acute fatigue recovery (p = 0.19). All intragroup analyses were significant (p ≤ 0.05) and all volunteers show a reduction in fatigue perception after treatment (p ≤ 0,05), however, exercise time did not ameliorate after TCA or DN (p > 0.77). A single session of TCA and, DN can equally reduce fatigue, temperature, and exercise time over PAF induced on biceps brachii of untrained healthy volunteers.

The widespread myofascial pain of fibromyalgia is sympathetically maintained and immune mediated

The recent demonstration of antibody-induced passive transfer of pain hypersensitivity from fibromyalgia (FM) subjects to mice brings renewed focus to the role of the immune system in generating FM pain. However, this data must be interpreted in the context of known myofascial pathology in FM, which includes impaired muscle relaxation and elevated intramuscular pressure. In addition, FM fascial biopsies demonstrate elevated inflammatory and oxidative stress markers and increased endomysial collagen deposition. This article proposes a unifying hypothesis for FM pain generation that connects known muscle and fascia abnormalities with the newly discovered role of antibodies. FM is characterized by persistent sympathetic nervous system hyperactivity which results in both pathologic muscle tension and an impaired tissue healing response. Although autoantibodies play a key role in normal tissue healing, sympathetic nervous system hyperactivity impairs the resolution of inflammation, and promotes autoimmunity and excessive autoantibody production. These autoantibodies can then bind with myofascial-derived antigen to create immune complexes, which are known to trigger neuronal hyperexcitability in the dorsal root ganglion. These hyperexcited sensory neurons activate the surrounding satellite glial cells and spinal microglia leading to pain hypersensitivity and central sensitization. Although immune system modulation may become an important treatment tool in FM, direct manual treatments that lessen myofascial inflammation and tension must not be neglected. Myofascial release therapy significantly reduces FM pain, with residual benefits even after the conclusion of treatment. Self-myofascial release techniques and gentle stretching programs also ease fibromyalgia pain, as do trigger point injections and dry-needling.

Are OMERACT recommendations followed in clinical trials on fibromyalgia? A systematic review of patient-reported outcomes and their measures

PURPOSE

Patient-Reported Outcomes (PROs) and its measures (PROMs) are key to outcome assessment in Fibromyalgia (FM) trials. The aim of this review was to investigate which domains and instruments were assessed in recent FM trials and to compare them to recommendations by the Outcome Measures in Rheumatology (OMERACT) initiative. In addition, we investigated the overlap with a generic health assessment approach, i.e. eight domains suggested by the Patient-Reported Outcome Measurement Information System® (PROMIS®).

METHODS

In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature search in scientific databases including PubMed, PsycInfo, and Embase was conducted to identify studies that assessed at least two dimensions of health-related quality of life (HRQoL) from 2015 to June 2022. Non-randomized and randomized controlled trials were included in the analysis. We extracted PROs and PROMs used in each study.

RESULTS

From 1845 identified records, 107 records out of 105 studies met the inclusion criteria. Studies investigated 50 PROs using 126 different PROMs. Most frequently assessed domains were pain, depression, fatigue, and anxiety (> 95% of the studies). The disease-specific FIQ was the most frequently applied PROM (82%). Overall, only 9% of the studies covered all domains deemed mandatory by OMERACT. Very few studies covered all eight generic health domains suggested by PROMIS.

CONCLUSION

The majority of trials covered most OMERACT domains or generic PROMIS health domains. There was, however, great variability in the instruments used to assess the domains, which points at a limited degree of standardization in the field.

Myofascial release for the treatment of pain and dysfunction in patients with chronic mechanical neck pain: Systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To explore the effects of myofascial release (MFR) on pain and dysfunction in individuals with chronic mechanical neck pain (MNP).

DATA SOURCES

PubMed, Embase, Medline, Wiley Online Library, Web of Science, CNKI, VIP, WanFang Data, and the Cochrane Library were searched until 12 September 2022.

REVIEW METHODS

This study was registered in PROSPERO (CRD42022302485). Methodological quality was assessed using Cochrane risk of bias assessment, and the quality of the evidence followed the GRADE recommendation. The outcomes pain, cervical mobility (Flexion, Extension, Rotation, lateral flexion), trapezius and suboccipital pressure pain thresholds (PPT), neck disability index (NDI), and adverse effects were extracted.

RESULTS

After screening of 346 studies, 13 studies and 601 participants met the inclusion criteria. All studies were of moderate methodological quality. Compared with the control group, the participants in the MFR group showed significantly greater improvements trapezius PPT SMD 0.41 (95% CI 0.11-0.72), suboccipital PPT SMD 0.47 (95% CI 0.21-0.72), respectively. The differences were not significant to support the MFR treatment on pain, flexion, extension, rotation, lateral flexion angle, and NDI. None of the studies reported any adverse events.

CONCLUSION

This systematic review suggests that MFR is an effective treatment for the improvement of PPT of trapezius and suboccipital muscle in patients with chronic MNP. However, there is low to moderate evidence and may change over time.

Myofascial Pain Syndrome: A Nociceptive Condition Comorbid with Neuropathic or Nociplastic Pain

Myofascial pain syndrome is featured by the presence of myofascial trigger points (TrPs). Whether TrPs are primary or secondary phenomena or if they relate to central or peripheral nervous system disorders is controversial. Referred pain, a cardinal sign of TrPs, is a central phenomenon driven by peripheral input. In 2021, the International Association for the Study of Pain (IASP) proposed a clinical criteria and grading system for classifying patients with pain on nociceptive, neuropathic, or nociplastic phenotypes. Myofascial TrP pain has been traditionally categorized as a nociceptive phenotype; however, increasing evidence supports that this condition could be present in patients with predominantly nociplastic pain, particularly when it is associated with an underlying medical condition. The clinical response of some therapeutic approaches for managing TrPs remains unclear. Accordingly, the ability to classify myofascial TrP pain into one of these phenotypes would likely be critical for producing more successful clinical treatment outcomes by a precision medicine approach. This consensus paper presents evidence supporting the possibility of subgrouping individuals with myofascial TrP pain into nociceptive, nociplastic, or mixed-type phenotype. It is concluded that myofascial pain caused by TrPs is primarily a nociceptive pain condition, is unlikely to be classified as neuropathic or nociplastic, but can be present in patients with predominantly neuropathic or nociplastic pain. In the latter cases, management of the predominant central pain problem should be a major treatment goal, but the peripheral drive from TrPs should not be ignored, since TrP treatment has been shown to reduce sensitization-associated symptomatology in nociplastic pain conditions, e.g., fibromyalgia.

Effectiveness of aquatic therapy on sleep in persons with fibromyalgia. A meta-analysis

CONTEXT

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal condition characterized by persistent, widespread pain, myofascial tenderness, negative affect, fatigue, memory problems and sleep disturbances.

OBJECTIVE

To summarize the evidence of the effects of aquatic therapy on sleep quality in patients with FMS.

METHODS

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2020 (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO), whit the registration number CRD42021249982. Cochrane library, Medline (PubMed), Science Direct Web of Science (WOS), Scopus, and PEDro were searched from inception until September 2021. The search included only randomized clinical trials.

RESULTS

Of the 7711 studies identified in the initial search, a total of 7 trials (361 participants) satisfied the eligibility criteria. Finally, a meta-analysis was conducted with 6 studies (311 participants). The overall pooled effect favored aquatic therapy interventions in improving sleep quality in patients with FMS (pooled MD, -2.05; 95% CI, -4.35 to 0.25).

CONCLUSIONS

The results of this systematic review and meta-analysis provide evidence that aquatic therapy improved sleep quality in patients with FMS. This study highlights the importance of aquatic therapy for sleep. Nonetheless, although an aquatic therapy intervention may represent a good option to improve sleep, given the low number of studies the evidence should be taken with caution.

Efficacy of Dry Needling and Acupuncture in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis

Fibromyalgia (FM) is a syndrome that involves chronic pain, fatigue, sleep disturbance and impaired quality of life and daily functioning. In addition to medical and psychological therapies, other therapies including acupuncture and dry needling aim to reduce pain and disability in patients with FM. The aim of this study was to investigate the efficacy of dry needling and acupuncture in patients with FM regarding pain, function and disability in both the short and the long term. MEDLINE, PubMed, SCOPUS and Web of Science databases were systematically searched for randomized controlled trial studies evaluating efficacy data of dry needling or/and acupuncture treatments to improve pain, fatigue, sleep disturbance and impaired quality of life and/or daily function. A qualitative analysis including the methodological quality and a systematic data synthesis was performed. A total of 25 studies addressed the selection criteria. Most studies had an acceptable methodological quality. Four studies assessed the effect of dry needling, and twenty-one studies assessed the effect of acupuncture. In general, both interventions improved pain, anxiety, depression, fatigue, stiffness, quality of sleep and quality of life. However, both techniques were not compared in any study. Acupuncture and dry needling therapies seems to be effective in patients with FM, since both reduced pain pressure thresholds, anxiety, depression, fatigue, sleep disturbances and disability in the short term. It is still required to compare both techniques and their application in the long term.

The Mediating Role of Depression and Pain Catastrophizing in the Relationship between Functional Capacity and Pain Intensity in Patients with Fibromyalgia

Background

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain condition characterized by widespread pain, sleep problems (i.e., insomnia and unrefreshing sleep), fatigue, cognitive, and emotional difficulties. Although pain has been proposed the factor mostly impacting in the FMS patients' function, emotional and psychological FMS-associated factors are also known to exert a negative impact in quality of life and functional capacity. Nonetheless, the relationship between these factors and functional limitations in FMS patients is considered to be complex and not clearly defined. Therefore, the present study is aimed at assessing the associations between FMS functional capacity, FMS symptoms (pain, fatigue, insomnia, depression, and state and trait anxiety), and associated psychological factors such as pain catastrophizing, as well as the possible mediating role of these latter in the relationship between pain and FMS functional capacity.

Method

115 women diagnoses with FMS completed a set of self-administered questionnaires to evaluate the clinical and psychological variables of the study.

Results

FMS functional capacity was positively associated with the majority of FMS symptoms except state anxiety. Regression analyses confirmed a greater prediction for FMS functional capacity by depression, fatigue, and pain catastrophizing, in this sequence. Both, pain catastrophizing and depression were important factors mediating the association between clinical pain (total and intensity) and FMS functional capacity.

Conclusions

Findings support a key role of pain catastrophizing and depression in the disability associated to pain in FMS. Treatment goals directed to lessen depression and pain catastrophizing levels should be promoted to reduce the impact of pain in FMS patients' daily function.

The Qigong of Prolong Life With Nine Turn Method Relieve Fatigue, Sleep, Anxiety and Depression in Patients With Chronic Fatigue Syndrome: A Randomized Controlled Clinical Study

Background

Chronic fatigue syndrome (CFS) is a complex disease of unknown etiology and mechanism. The purpose of this study was to investigate the effect of Prolong Life with Nine Turn Method (PLWNT) Qigong exercise on CFS focusing on fatigue, sleep quality, depression, and anxiety.

Methods

A total of 90 participants diagnosed with CFS were randomly assigned into two parallel groups: PLWNT and cognitive behavioral therapy (CBT). The participants in the PLWNT or CBT group participated in qigong exercise or cognitive behavior education program, respectively, once a week in-person and were supervised online during the remaining 6 days at home, over 12 consecutive weeks. The primary outcome was fatigue (Multi-dimensional Fatigue Inventory 20 [MFI-20]), and secondary outcomes were sleep quality (Pittsburgh Sleep Quality Index [PSQI]), anxiety, depression (Hospital Anxiety and Depression Scale [HADS]), and changes in the Neuropeptide Y (NPY) of peripheral blood.

Results

The within-group comparisons of the PLWNT and CBT groups revealed significant improvement in both groups in MFI-20, PSQI, and HADS scores (P &lt; 0.05). No significant difference were found between the PLWNT and CBT groups, even though the effective rate of the PLWNT group was 62.22%, which is slightly than 50.00% of the CBT group. The fatigue scores in the PLWNT group were positively correlated with sleep degree (r = 0.315) and anxiety degree (r = 0.333), only anxiety degree (r = 0.332) was found to be positively correlated with fatigue in the CBT group. The analysis of peripheral blood showed that NPY decreased after PLWNT intervention but increased significantly in the CBT.

Conclusion

The PLWNT qigong exercise has potential to be an effective rehabilitation method for CFS symptoms including fatigue, sleep disturbance, anxiety, and depression. Future studies should expand study sample size for in-depth investigation to determine the optimal frequency and intensity of PLWNT qigong intervention in CFS patients. The study was registered in the ClinicalTrials.gov database on April 12, 2018, with registration number NCT03496961.

Selected needling techniques in pain associated with musculoskeletal disorders: a narrative review

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Scoping review and interpretation of myofascial pain/fibromyalgia syndrome: An attempt to assemble a medical puzzle

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.

Effectiveness of non-pharmacological conservative therapies in adults with fibromyalgia: A systematic review of high-quality clinical trials

BACKGROUND

Fibromyalgia is a chronic condition characterized by generalized pain. Several studies have been conducted to assess the effects of non-pharmacological conservative therapies in fibromyalgia.

OBJECTIVE

To systematically review the effects of non-pharmacological conservative therapies in fibromyalgia patients.

METHODS

We searched MEDLINE, Cochrane library, Scopus and PEDro databases for randomized clinical trials related to non-pharmacological conservative therapies in adults with fibromyalgia. The PEDro scale was used for the methodological quality assessment. High-quality trials with a minimum score of 7 out of 10 were included. Outcome measures were pain intensity, pressure pain threshold, physical function, disability, sleep, fatigue and psychological distress.

RESULTS

Forty-six studies met the inclusion criteria. There was strong evidence about the next aspects. Combined exercise, aquatic exercise and other active therapies improved pain intensity, disability and physical function in the short term. Multimodal therapies reduced pain intensity in the short term, as well as disability in the short, medium and long term. Manual therapy, needling therapies and patient education provided benefits in the short term.

CONCLUSIONS

Strong evidence showed positive effects of non-pharmacological conservative therapies in the short term in fibromyalgia patients. Multimodal conservative therapies also could provide benefits in the medium and long term.

Evaluating the Relationship Between Myofascial Pain Syndrome (MPS) and Physical and Mental Health Status in Patients with Stroke

Background: Myofascial pain syndrome (MPS) is a non-inflammatory disorder with muscle stiffness and pain that occurs with the appearance of palpable and irritating nodules in the muscular system. Stroke is one of the most common neurological diseases that in many cases leads to disability and reduction of quality of life (QOL). Objectives: This study aimed to evaluate the relationship between MPS and physical and mental health (MH) status in patients with stroke. Methods: Using available sampling method, this case-control study included 260 patients with stroke. To collect data, demographic characteristics, Visual Analogue Scale (VAS), 36-item Short Form Survey (SF-36), and Depression, Anxiety and Stress Scale (DASS-21) were used. Data analysis was performed using SPSS 16. Mean and standard deviation were used for descriptive statistics and independent t-test, paired t-test, and analysis of variance (ANOVA) were used for inferential tests. Results: While the pain score was 6.35 (1.39), QOL score was 38.86 (11.69), and MH score was 16.26 (2.75) in the intervention group, these scores were 2.15 (0.96), 63.96 (17.52), and 9.02 (4.63), respectively, in the control group. The results showed no statistically significant relationship between MPS and QOL. But there was a statistically significant relationship between MPS and MH, so that the MH status of patients with MPS was lower than the MH status of other patients. Conclusions: Necessary interventions have been done to improve the health status of patients with MPS, which will lead to an increase in the health status of these patients.

Is Irritable Bowel Syndrome Considered as Comorbidity in Clinical Trials of Physical Therapy Interventions in Fibromyalgia? A Scoping Review

Evidence supports the presence of comorbid conditions, e.g., irritable bowel syndrome (IBS), in individuals with fibromyalgia (FM). Physical therapy plays an essential role in the treatment of FM; however, it is not currently known whether the IBS comorbidity is considered in the selection criteria for clinical trials evaluating physiotherapy in FM. Thus, the aim of the review was to identify whether the presence of IBS was considered in the selection criteria for study subjects for those clinical trials that have been highly cited or published in the high-impact journals investigating the effects of physical therapy in FM. A literature search in the Web of Science database for clinical trials that were highly cited or published in high-impact journals, i.e., first second quartile (Q1) of any category of the Journal Citation Report (JCR), investigating the effects of physical therapy in FM was conducted. The methodological quality of the selected trials was assessed with the Physiotherapy Evidence Database (PEDro) scale. Authors, affiliations, number of citations, objectives, sex/gender, age, and eligibility criteria of each article were extracted and analyzed independently by two authors. From a total of the 412 identified articles, 20 and 61 clinical trials were included according to the citation criterion or JCR criterion, respectively. The PEDro score ranged from 2 to 8 (mean: 5.9, SD: 0.1). The comorbidity between FM and IBS was not considered within the eligibility criteria of the participants in any of the clinical trials. The improvement of the eligibility criteria is required in clinical trials on physical therapy that include FM patients to avoid selection bias.

Effectiveness of myofascial release on pain, sleep, and quality of life in patients with fibromyalgia syndrome: A systematic review

BACKGROUND AND PURPOSE

There is limited evidence on the effects of myofascial release on fibromyalgia symptoms. This review aims to update the evidence on the effectiveness of myofascial release on pain, sleep, and quality of life in patients with fibromyalgia syndrome.

METHODS

The review was prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, Cochrane Library, Physiotherapy Evidence Database, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature Complete, and ProQuest Medical library were searched from their inception to April 1, 2021 for randomized or nonrandomized clinical trials published in English. Studies consisting of myofascial release alone or in combination with exercise as the intervention were included. The quality of the studies was evaluated using Cochrane Risk of Bias 2.0.

RESULTS

Six studies, including a total of 279 participants, were included in the review. The meta-analysis showed a large significant effect of myofascial release on pain posttreatment (-0.81[95% CI = -1.15 to -0.47], p < 0.00001) and a moderate effect at 6 months post-treatment (-0.61, 95% CI = -0.95 to -0.28, p = 0.0003).

CONCLUSION

The review demonstrated moderate evidence for the effect of therapist administered and self-myofascial release in improving pain, sleep subscales, and quality of life against sham and no treatment, respectively, in fibromyalgia syndrome patients. However, more high-quality randomized controlled trials with manual control group are required to be conducted at different geographical locations to generalize the findings.

Current advances and novel research on minimal invasive techniques for musculoskeletal disorders

The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.

The Effect of Aromatherapy with Lavender Oil on the Health-Related Quality of Life in Patients with Fibromyalgia

The aim of this study was to evaluate the effect of lavender oil, which has been used in complementary medicine as an aromatherapeutic, on the health-related quality of life in patients diagnosed with fibromyalgia and to determine the main volatile compounds of lavender oil with healing effects. Forty-two patients aged 18 years and over who were diagnosed with fibromyalgia according to the American College of Rheumatology 2010 diagnostic criteria and used lavender oil as an aromatherapeutic by applying it on the wrist or via inhalation for four weeks were included in this study. The Short-Form (SF)-36 Quality of Life Scale was administered to the patients at baseline and after four weeks of lavender oil treatment to determine whether there was any change in their quality of life. The averages and correlation levels between the scores were calculated with the paired-sample t-test taking $p$  < 0.05 as the statistical significance limit. In addition, the chromatographic analysis of lavender oil was performed with the combined headspace solid-phase microextraction and gas chromatography-mass spectrometry methods. When the quality of life scores were evaluated at baseline and after four weeks of lavender oil treatment, improvements were detected in all the subscales of SF-36 at the end of the study. It was found that all the subscale scores, except for general health, were statistically significantly higher compared to the baseline scores ( $p$  < 0.05). The major volatile compounds detected in lavender oil were linalool (29.33%) and linalyl acetate (27.69%). The remaining main compounds were terpinolene, cis-ocimene, eucalyptol, and lavandulol in the order of frequency, which is consistent with the literature. To our knowledge, this is the first study investigating the effect of lavender oil aromatherapy on patients diagnosed with fibromyalgia, and our results support that lavender oil aromatherapy significantly improves the quality of life in these patients. However, further comprehensive studies are needed to confirm our findings.

Pain Intensity and Sensory Perception of Tender Points in Female Patients with Fibromyalgia: A Pilot Study

Fibromyalgia syndrome (FMS) is a condition that courses with chronic pain, fatigue, sleep disturbance, impaired quality of life and daily function. Due to the lack of blood, imaging or histological confirmatory tests, the diagnosis of FMS is based on the presence of widespread pain and presence of tender points (TPs). Our aim was to assess the pain pressure thresholds (PPTs) and subjective pain perception (SPP) of all 18 TPs while applying a normalized pressure in female patients with fibromyalgia. An exploratory descriptive pilot study was conducted in 30 female patients with FMS. Sociodemographic data (e.g., age, height, weight, and body mass index), clinical characteristics (e.g., years with diagnosis and severity of FMS), PPTs (assessed with an algometer), and SPP (assessed with a visual analogue scale) of all 18 TPs were collected. A comparative analysis side-to-side (same TP, left and right sides) and between TPs was conducted. No side-to-side differences were found (p < 0.05). Significant differences between all 18 TPs were found for PPTs (p < 0.0001), and SPP (p < 0.005) scores were found. The most mechanosensitive points were located in the second costochondral junction, the occiput, the trochanteric prominence; the most painful while applying a normalized pressure considering the TP and side were those located in the gluteus, trochanteric prominence, and supraspinatus. The current study describes PPTs and SPP, as assessed with algometry and visual analogue scale, respectively, of all 18 TPs in female patients with FMS. TPs exhibited significant PPTs and SPP differences between TP locations with no side-to-side differences.

Effectiveness of Invasive Techniques in Patients with Fibromyalgia: Systematic Review and Meta-Analysis

OBJECTIVE

To attain a synthesis of the evidence on the effectiveness of invasive techniques in patients with fibromyalgia, through systematic review and meta-analysis and by assessing the methodological quality of the studies considered.

METHODS

A systematic review and meta-analysis were carried out as defined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The bibliographic research was carried out in the PEDro, Cochrane, PubMed, Science Direct, Web of Science, Google Academics, Dialnet, and Scielo databases from September through December of 2018.

RESULTS

Results show that invasive techniques produce a significant decrease in the pain, the impact of fibromyalgia and in the pain pressure threshold (standardized mean difference [95% confidence interval]: -0.94 [-1.44, -0.44], P of global effect= 0.0002; -0.99 [-1.69, -0.29], P of global effect= 0.006; and 0.31 [0.02, 0.61], P of global effect = 0.04, respectively). Lastly, a significant increase was observed in the quality-of-life variable after intervention (0.84 [0.30, 1.38], P of global effect = 0.002).

CONCLUSIONS

Invasive techniques are considered effective for pain relief, as well as for producing a short-term increase in the pain pressure threshold, an improvement in quality of life, and a decrease in the impact of fibromyalgia.

Effectiveness of Dry Needling versus Placebo on Gait Performance, Spasticity, Electromyographic Activity, Pain, Range-of-Movement and Quality of Life in Patients with Multiple Sclerosis: A Randomized Controlled Trial Protocol

Dry needling (DN) is an emerging technique commonly used in neurological and musculoskeletal pain conditions, but there have been no previous studies in patients with multiple sclerosis (pwMS). This trial aims to assess the efficacy of deep DN, compared with sham placebo DN, on gait performance, spasticity level, pain, electromyographic activity, range-of-movement (ROM) and quality of life in pwMS. Forty adults with MS were randomly assigned to one study group. The DN group will undergo 2 sessions (once per week) using DN over the rectus femoris (RF) and gastrocnemius medialis (GM) muscles at the lower extremity with higher spasticity. The placebo group will receive the same protocol using a sham placebo needle (Dong Bang needle). Outcome measures will include gait performance, using the GaitRite^® system, spasticity level with the Modified Ashworth Scale, superficial electromyographic activity of RF and GM, pain (pressure algometer), ROM (goniometer), and quality of life (Musiqol). This study is the first investigating the short-term effect of DN, compared with placebo, in pwMS, and taking into account the possible changes in the electromyographic activity of the lower limb. Therefore, the results may help to understand the suitability of using this technique in the clinical setting for this population. Trial registration: ACTRN12619000880145.

Quality of life related to foot health status in women with fibromyalgia: a case-control study

INTRODUCTION

To date, the Foot Health Status Questionnaire (FHSQ) has not been applied to women who suffer from fibromyalgia. The main purpose of this study was to compare both foot and general health-related quality of life between women with fibromyalgia and healthy matched women. We hypothesized that women with fibromyalgia may present an impaired quality of life related to foot and general health.

MATERIAL AND METHODS

A sample of 208 women, mean age of 55.00 ±8.25 years, was recruited from an outpatient clinic and divided into 2 groups, 104 women with fibromyalgia (for the case group) and 104 healthy matched women (for the control group). Demographic data and the domains of the FHSQ scores were registered.

RESULTS

Statistically significant differences (p < 0.001) between case and control groups were found for both all specific foot domains (pain, foot function, foot health and footwear) and all general wellbeing domains (general health, physical activity, social capacity and vigor), showing a worse foot and general health-related quality of life (with lower scores for all FHSQ domains) in the women with fibromyalgia compared to healthy matched women.

CONCLUSIONS

Impaired foot and general health-related quality of life was observed in women who suffered from fibromyalgia compared to healthy matched women.