Myofascial Pain Syndrome of the Abdominal Wall for the Busy Clinician

The Diagnostic Value of Carnett's Test with Chronic Abdominal Pain: A Narrative Review

PURPOSE OF REVIEW

Chronic abdominal wall pain is a poorly recognized cause of chronic abdominal pain, and patients frequently go misdiagnosed despite a battery of medical tests. The Carnett's test is a diagnostic tool used to distinguish between abdominal wall pain and visceral pain. This review synthesizes the current literature on the Carnett's test, merges the viewpoints of diverse writers, and evaluates and reports on the Carnett's test's applicability.

RECENT FINDINGS

Several clinical investigations have established the usefulness of the Carnett's test in the diagnosis of chronic abdominal wall pain. Furthermore, the Carnett's test is quite useful in determining the depth of the mass and detecting psychogenic abdominal pain. However, its diagnostic use for acute abdominal pain is limited. The Carnett's test is a simple and safe point-of-care diagnostic technique, with several studies supporting its usefulness. Early detection of abdominal wall pain is critical for chronic abdominal wall pain therapy. Carnett's test is very useful in patients with chronic, unexplained local abdominal discomfort who are compliant and do not have a clear rationale for surgery.

Therapeutic ultrasound versus injection of local anesthetic in the treatment of women with chronic pelvic pain secondary to abdominal myofascial syndrome: a randomized clinical trial

BACKGROUND

Chronic pelvic pain (CPP) is defined as recurrent or continuous pain in the lower abdomen or pelvis, either non-menstrual or noncyclical, lasting for at least 6 months. There is strong evidence that up to 85% of patients with CPP have serious dysfunctions of the musculoskeletal system, including abdominal myofascial pain syndrome (AMPS). AMPS is characterized by intense and deep abdominal pain, originating from hyperirritable trigger points, usually located within a musculoskeletal band or its lining fascia. In the literature, there are few studies that address AMPS.

OBJECTIVES

To evaluate and compare the efficacy of therapeutic ultrasound (TUS) and injection of local anesthetic (IA) to improve pain in women with abdominal myofascial syndrome secondary to CPP.

STUDY DESIGN

Randomized controlled clinical trial.

SETTING

Tertiary University Hospital.

MATERIALS AND METHODS

A randomized clinical trial was conducted, patients were allocated to two types of treatment: group TUS (n = 18), and group IA (n = 20). The instruments used for evaluation and reassessment were the Visual Analog Scale, Numerical Categorical Scale, McGill Pain Questionnaire, and SF-36 quality of life assessment questionnaire. They were evaluated before starting treatment, 1 week after the end of treatment, and at 1, 3, and 6 months.

RESULTS

TUS and IA were effective in reducing clinical pain and improving quality of life through the variables analyzed among study participants. There was no significant difference between groups.

LIMITATIONS

absence of blinding; exclusion of women with comorbidities and other causes of CPP, the absence of a placebo group, the difference between the number of sessions used for each technique, and the COVID-19.

CONCLUSION

Treatment with TUS and IA were effective in reducing clinical pain and improving quality of life in women with AMPS secondary to CPP.

TRAIL REGISTRATION

We declare that this clinical trial has been registered under the number [(ReBEC) no. RBR-39czsv] on 07/18/2018 in the Brazilian Registry of Clinical Trials.

Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218

Chronic pelvic pain is a common, burdensome, and costly condition that disproportionately affects women. Diagnosis and initial management of chronic pelvic pain in women are within the scope of practice of specialists in obstetrics and gynecology. The challenging complexity of chronic pelvic pain care can be addressed by increased visit time using appropriate coding modifiers, as well as identification of multidisciplinary team members within the practice or by facilitated referral. This Practice Bulletin addresses the diagnosis and management of chronic pelvic pain that is not completely explained by identifiable pathology of the gynecologic, urologic, or gastrointestinal organ systems. When evidence on chronic pelvic pain treatment is limited, recommendations are extrapolated from treatment of other chronic pain conditions to help guide management. The evaluation and management of potential gynecologic etiologies of pelvic pain (ie, endometriosis, adenomyosis, leiomyomas, adnexal pathology, vulvar disorders) are discussed in other publications of the American College of Obstetricians and Gynecologists ().

Safety and efficacy of ilioinguinal and iliohypogastric nerve blocks for treatment of pelvic pain

Objective:

To assess the safety and efficacy of ilioinguinal/iliohypogastric nerve blocks for patients with lower abdominal wall pain in a gynaecology setting.

Methods:

A retrospective chart review of 131 patients who received ilioinguinal/iliohypogastric nerve blocks at a tertiary referral centre for pelvic pain between 1 January 2012 and 13 July 2017 was performed. Patient demographics, history, examination findings and block data were extracted. Chi-square and Mann–Whitney U tests explored differences in patient characteristics between patients with and without effective response to their initial ilioinguinal/iliohypogastric nerve block.

Results:

A total of 465 ilioinguinal/iliohypogastric nerve blocks were performed among patients. The effect of the initial block was available for 99 out of 131 patients. Of these patients, 70% (n = 69) reported a great improvement in pain, 9% (n = 9) some improvement in pain, 18% (n = 18) no response and 3% (n = 3) worsening of pain. A significantly greater number of patients who were not responsive to their first block reported unilateral pain (p = 0.040) and had a history of vulvodynia (p = 0.038) when compared to patients who were responsive to their first block. Seven patients (5%) reported minor adverse events related to blocks.

Conclusion:

Ilioinguinal/iliohypogastric nerve blocks provide pain relief for those with pelvic pain localized to the lower abdominal wall, with a low rate of minor adverse events.

Effect of Acupuncture on Chronic Pelvic Pain Secondary to Abdominal Myofascial Syndrome Not Responsive to Local Anesthetic Block: A Pilot Study

Objective: Strong evidence shows that 85% of women with chronic pelvic pain (CPP) have musculoskeletal disorders, such as abdominal myofascial pain syndrome (AMPS). The aim of this research was to assess the efficacy of local acupuncture treatment for women with CPP secondary to AMPS unresponsive to treatment with trigger-point injection. Materials and Methods: This pilot study involved 17 women with moderate-to-severe AMPS-related CPP. Acupuncture treatments were given at abdominal-wall trigger points once per week for 10 consecutive weeks. Pain relief was assessed with a visual analogue scale (VAS), the McGill questionnaire, and pressure dynamometer. Quality of life and psychosocial function (risk for anxiety and depression) were evaluated using the Short-Form-36 questionnaire and the Hospital Anxiety and Depression scale. Assessments were performed at baseline and after 1, 3, and 6 months of treatment. Results: Both the VAS and McGill pain questionnaire showed significantly decreased pain intensity (VAS, P < 0.001; and McGill, P 0.049), and the effects were sustained even at 6 months after treatment. Conclusions: Acupuncture treatment was effective for the women who participated in this study, and the current authors believe that these preliminary results suffice to recommend performing randomized controlled trials.

Evaluation of Women with Myofascial Abdominal Syndrome Based on Traditional Chinese Medicine

Objectives:

This study used semiology based on traditional Chinese medicine (TCM) to investigate vital energy (Qi) behavior in women with abdominal myofascial pain syndrome (AMPS).

Methods:

Fifty women diagnosed with chronic pelvic pain (CPP) secondary to AMPS were evaluated by using a questionnaire based on the theories of “yin-yang,” “zang-fu”, and “five elements”. We assessed the following aspects of the illness: symptomatology; specific location of myofascial trigger points (MTrPs); onset, cause, duration and frequency of symptoms; and patient and family history. The patients tongues, lips, skin colors, and tones of speech were examined. Patients were questioned on various aspects related to breathing, sweating, sleep quality, emotions, and preferences related to color, food, flavors, and weather or seasons. Thirst, gastrointestinal dysfunction, excreta (feces and urine), menstrual cycle, the five senses, and characteristic pain symptoms related to headache, musculoskeletal pain, abdomen, and chest were also investigated.

Results:

Patients were between 22 and 56 years old, and most were married (78%), possessed a elementary school (66%), and had one or two children (76%). The mean body mass index and body fat were 26.86 kg/ cm2 (range: 17.7 — 39.0) and 32.4% (range: 10.7 — 45.7), respectively. A large majority of women (96%) exhibited alterations in the kidney meridian, and 98% had an altered gallbladder meridian. We observed major changes in the kidney and the gallbladder Qi meridians in 76% and 62% of patients, respectively. Five of the twelve meridians analyzed exhibited Qi patterns similar to pelvic innervation Qi and meridians, indicating that the paths of some of these meridians were directly related to innervation of the pelvic floor and abdominal region.

Conclusion:

The women in this study showed changes in the behavior of the energy meridians, and the paths of some of the meridians were directly related to innervation of the pelvic floor and abdominal region.

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Quantification of abdominal wall pain using pain pressure threshold algometry in patients with chronic pelvic pain

OBJECTIVE

Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis, which includes pain from the lower anterior abdominal wall. This entity has been termed myofascial pain syndrome (MFPS), but its characteristics, definition, and quantification have not been well described. In this study, pain pressure threshold (PPT) testing of the lower anterior abdominal wall in CPP patients was performed to determine the range and distribution of values at each site, and the clinical utility of using PPT in a definition of MFPS.

METHODS

Fifty-six patients evaluated in a CPP specialty clinic underwent PPT algometry of 14 sites on the lower anterior abdominal wall. These values were described and evaluated before and after treatment. PPT values were also evaluated in patients found to be drug seeking.

RESULTS

Twenty percent of the PPT tests reached the threshold of 3 kgf/cm2. The abnormal tests usually formed a normal distribution. PPT testing had a weak but appropriate correlation with other pain symptom measures. After trigger point injection there was a 75% improvement in PPT, and response to medical therapy resulted in a 60% improvement. A composite measure was able to distinguish drug-seeking patients with statistical accuracy.

DISCUSSION

PPT testing can be used to evaluate MFPS in CPP patients. One suggested definition would exclude patients with low scores in the upper abdomen while including patients with low scores in the lower abdomen.

Chronic abdominal wall pain--a diagnostic challenge for the surgeon

BACKGROUND

Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain.

METHODS

The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain.

RESULTS

CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology.

CONCLUSION

The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

Physical therapy in the management of women with chronic pelvic pain

OBJECTIVES

Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy.

METHODS

We evaluated data available in PubMed (1984-2006) and surveyed the reference list. Three reviewers analysed the data independently, considering a study to be of high quality if it had at least three of the following characteristics: prospective design, valid measurement instruments, and adequate sample estimate and response rate. Other studies such as retrospective investigations, reviews and expert opinions were also considered, but with decreasing emphasis.

RESULTS

There are evidences of musculoskeletal system disorders in most women with CPP. These musculoskeletal disorders can be the primary cause of CPP or postural changes and pelvic muscle contractures secondary to CPP.

CONCLUSIONS

Synchronised intervention by physicians and physiotherapists is becoming increasingly more necessary both in terms of a more refined diagnosis of the clinical situation and of the institution of effective and lasting treatment.