Treating myofascial pain with dry needling: a systematic review for the best evidence-based practices in low back pain

BACKGROUND

 Myofascial pain syndrome (MPS) is a common source of pain in primary care or pain clinics. There are many different ways to manage and treat MPS, such as physical exercise, trigger points massage, and dry needling.

OBJECTIVE

 The objective of this overview is to highlight and discuss the evidence-based treatment of myofascial pain by dry needling in patients with low back pain.

METHODS

 A systematic review was made based on meta-analysis (MA) and randomized controlled trials (RCTs) related to dry needling treatment for myofascial pain in patients with lumbar pain, published from 2000 to 2023.

RESULTS

 A total of 509 records were identified at first. Seventy were published before 2000, so they were excluded. From the remaining 439 studies, ninety-two were RCTs or MA, of which 86 additional studies were excluded for the following reasons: not related to dry needling treatment (n = 79), not published in English (n = 4), duplicated (n = 1), project protocol (n = 1), and not related to myofascial pain (n = 1). So, this review was based on 4 RCTs and two MA. These studies compared dry needling efficacy to other treatments, such as acupuncture, sham dry needling, laser therapy, physical therapy, local anesthetic injection, ischemic compression, and neuroscience education. Despite outcomes and follow-up period varied between them, they showed that dry needling can decrease post-intervention pain intensity and pain disability.

CONCLUSION

 Dry needling is an effective procedure for the treatment of myofascial pain in patients with acute and chronic low back pain. Further high-quality studies are needed to clarify the long-term outcomes.

Chronic Unilateral Headache Related to Scar Neuromas

Postcraniotomy and posttraumatic headaches can result in scars generating local pain or referred pain following a neuropathic pattern. One hypothesis is that the pain can be caused and maintained by scar neuromas, developed after the nerve injury during the surgical process or trauma. This study reports two patients with chronic unilateral headaches: the first one with a posttraumatic scar in the parietal region and the other with a postsurgical scar in the mastoid region. In both patients, the headache was ipsilateral to the scar, suggesting primary headaches (trigeminal autonomic cephalalgia (TAC), as hemicrania continua and chronic cluster headache). Pharmacological treatment for these conditions failed. Instead, there was complete remission of the headache with anesthetic blockade of scar neuromas (demonstrated by clinical examination in both patients). An active search for traumatic or nontraumatic scars is recommended in all patients with refractory unilateral headaches, and anesthetic blocks for scar neuromas can be effective in treating this pain.

Chronic migraine patients show cognitive impairment in an extended neuropsychological assessment

OBJECTIVES

The objective of the present study was to assess the presence of cognitive deficits in patients with chronic migraine, and to assess the main factors that trigger cognitive disorders, such as comorbidities or the use of medications.

METHODS

Chronic migraine and control groups were interviewed in a case-control study. The frequency and intensity of the headache, medication used and associated comorbidities were determined. All patients were submitted to an extended neuropsychological assessment.

RESULTS

The chronic migraine group (n = 30) had a worse performance in the Montreal Cognitive Assessment Test (p = 0.00), Verbal Fluency (p = 0.00), Stroop (p = 0.00), Clock Drawing Test (p = 0.00), Digit Span (p = 0.00) and Matrix Reasoning (p = 0.01). After statistical adjustment by linear regression, migraine continued to be the only relevant factor in the poorer performance in the Montreal Cognitive Assessment, Verbal Fluency, Clock Drawing and Stroop tests.

CONCLUSIONS

Patients with chronic migraine have cognitive deficits in multiple tasks, regardless of the presence of comorbidities or the use of medications.

Women Living Together Have a Higher Frequency of Menstrual Migraine

BACKGROUND

Menstrual migraine is a highly prevalent disorder among adult women, resulting in disability and loss of quality of life. Some studies have reported menstrual cycle synchrony among women living together. No study has reported whether there may also be a higher prevalence of menstrual migraine among these women. Thus, they reported here the prevalence of menstrual migraine in a group of women living together compared with a control group of women living alone, and discussed the possible factors involved.

METHODS

The study was conducted on female university students aged 18-30 years with a diagnosis of migraine according to the criteria of the International Classification of Headache Disorders III, beta appendix criteria. The subjects were divided into a group of women who lived together with two or more other students and a control group of age-matched students who lived alone, interviewed with a specific questionnaire and assessed for 3 months by means of a paper pain diary. The data evaluated included frequency of headache, presence of menstrual migraine, intensity of headache, medications used including contraceptives, and triggering factors such as diet, sleep deprivation, and stress. The menstrual data and data related to migraine were also investigated in the roommates.

RESULTS

A higher occurrence of menstrual migraine among women living together (9, 50%) compared with women living alone (3, 16.7%) (P = .03) was detected. After binary logistic regression analysis, this finding was not related to the main influencing factors detected, that is, use of a contraceptive, test stress, or sleep deprivation (P = .03, adjusted odds ratio: 7.87; 1.23-50.36). These women also showed menstrual cycle synchrony with their roommates (8, 44.4%) and the presence of headache crises during the menstruation of their colleagues (11, 61.1%).

CONCLUSION

The present study detected a higher occurrence of menstrual migraine among women who lived together. Since there was no previous description of this topic in the literature, it was believed that the present study could represent a step toward more elaborate investigations of this complex topic.

Comparative genomics of the major fungal agents of human and animal Sporotrichosis: Sporothrix schenckii and Sporothrix brasiliensis

BACKGROUND

The fungal genus Sporothrix includes at least four human pathogenic species. One of these species, S. brasiliensis, is the causal agent of a major ongoing zoonotic outbreak of sporotrichosis in Brazil. Elsewhere, sapronoses are caused by S. schenckii and S. globosa. The major aims on this comparative genomic study are: 1) to explore the presence of virulence factors in S. schenckii and S. brasiliensis; 2) to compare S. brasiliensis, which is cat-transmitted and infects both humans and cats with S. schenckii, mainly a human pathogen; 3) to compare these two species to other human pathogens (Onygenales) with similar thermo-dimorphic behavior and to other plant-associated Sordariomycetes.

RESULTS

The genomes of S. schenckii and S. brasiliensis were pyrosequenced to 17x and 20x coverage comprising a total of 32.3 Mb and 33.2 Mb, respectively. Pair-wise genome alignments revealed that the two species are highly syntenic showing 97.5% average sequence identity. Phylogenomic analysis reveals that both species diverged about 3.8-4.9 MYA suggesting a recent event of speciation. Transposable elements comprise respectively 0.34% and 0.62% of the S. schenckii and S. brasiliensis genomes and expansions of Gypsy-like elements was observed reflecting the accumulation of repetitive elements in the S. brasiliensis genome. Mitochondrial genomic comparisons showed the presence of group-I intron encoding homing endonucleases (HE's) exclusively in S. brasiliensis. Analysis of protein family expansions and contractions in the Sporothrix lineage revealed expansion of LysM domain-containing proteins, small GTPases, PKS type1 and leucin-rich proteins. In contrast, a lack of polysaccharide lyase genes that are associated with decay of plants was observed when compared to other Sordariomycetes and dimorphic fungal pathogens, suggesting evolutionary adaptations from a plant pathogenic or saprobic to an animal pathogenic life style.

CONCLUSIONS

Comparative genomic data suggest a unique ecological shift in the Sporothrix lineage from plant-association to mammalian parasitism, which contributes to the understanding of how environmental interactions may shape fungal virulence. . Moreover, the striking differences found in comparison with other dimorphic fungi revealed that dimorphism in these close relatives of plant-associated Sordariomycetes is a case of convergent evolution, stressing the importance of this morphogenetic change in fungal pathogenesis.

Identification of phenotypic markers of B cells from patients with Chagas disease

Chagas disease was discovered more than a hundred years ago, but its pathogenesis is still not completely understood. Autoimmunity is one of the mechanisms shown to contribute to its pathogenesis, which may indicate an important participation of B lymphocytes. Patients with Chagas disease have shown increased percentage of B cells producing IL-10. However, there are no reports of the phenotypic markers of B cells producing IL-10 in patients with Chagas disease. For the first time in the literature, we evaluated the phenotypic profile of distinct markers of B cells from peripheral blood of noninfected individuals and patients with Chagas disease. Our results showed that patients with Chagas disease had a higher expression of CD21 and CD24 on the surface of CD19+ B cells, while CD43 and CD23 were expressed equally in all groups. Moreover, the expression of MHC-II (HLA-DR), CD80, CD86, caspase-3, granzyme B and intracellular IL-10 and TGF-β by CD19+ B cells was higher in patients with Chagas disease. The results of IL-10 production within CD19+ CD5+ CD1d+ B cells showed a higher percentage of this cytokine in patients with Chagas disease. Thus, our data bring a new knowledge about distinct markers of B cells in immune responses of Chagas disease.

Chemical composition and antimicrobial activity of essential oils from Chromolaena laevigata during flowering and fruiting stages

The chemical compositions and antimicrobial activities of essential oils from the leaves, stems, capitula, and cypselas of Chromolaena laevigata were evaluated at two different phenological stages, flowering and fruiting. Thirty-eight compounds were identified in the crude oils by GC/MS. The sesquiterpene laevigatin was the major constituent of the leaf, capitulum, and cypsela oils, while the sesquiterpene spathulenol was the main component in the stem oils. The antimicrobial activities of the oils were evaluated against Candida albicans, Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli. Stem oil obtained from Chromolaena laevigata during the fruiting stage generally showed the highest activity with minimum inhibitory concentration (MIC) values of 62.5 μg/ml against Candida albicans and S. aureus, and 500 μg/ml against P. aeruginosa and E. coli. Pure laevigatin exhibited MIC values of 500 and 125 μg/ml against C. albicans and S. aureus, respectively, indicating that this constituent could be responsible, at least in part, for the antimicrobial activities detected in the crude oils. More studies concerning the biological activities of isolated derivatives are required to improve our knowledge of the antimicrobial potential of volatile compounds present in native plants.

Comorbidities, medications and depressive symptoms in patients with restless legs syndrome and migraine

OBJECTIVE

The pathophysiology of migraine and restless legs syndrome (RLS) seems to involve inherited mechanism and dysfunction of the dopaminergic system. Previous articles have shown that the frequency of RLS is higher in migraine patients than in controls. We conducted a study to evaluate comorbidities, medication used and depressive symptoms that can explain the relation between migraine and RLS.

METHODS

A case-control study was performed in which patients with migraine (n=72) and a control group without migraine (n=72) were interviewed. Data including RLS diagnosis, depressive symptoms, comorbidities and drugs used were evaluated.

RESULTS

There was a significant association between migraine and RLS (p=0.01), but comorbidities such as diabetes, hypertension, anemia and drugs used did not explain this association. Depression scores, as measured by the Beck Depression Inventory, were higher in migraine patients with RLS (p =0.04).

CONCLUSION

No specific factors explaining the association between migraine and RLS were found. Symptoms of depression were more frequent in patients with migraine and RLS.

Is there a relation between hemicrania continua and leprosy?

The association of hemicrania continua and leprosy has been described in 2008. This relation can be causal or casual. Hemicrania continua is a strictly unilateral, moderate to severe, continuous, indomethacin-responsive primary headache with autonomic cranial symptoms and leprosy is an usual cause of peripheral neuropathy. Prevalence has fallen in the past years, but transmission continues and leprosy remains a public health problem. The objective of this study is to report one case of headache fulfilling the IHS criteria for HC, presented during the course of leprosy. A 61 years old woman started hypo and hiperpigmented lesions with impaired sensation to touch on right side of face (malar). She had biopsy in facial lesion and histopathology compatible with a borderline leprosy form. At the same time, she reported new headaches, daily and continuous, without pain-free periods, unilateral (which were located in the same side of the leprosy lesion in face), throbbing and severe (VAS = 8) with ipsilateral conjuntival injection and lacrimation that improved with indomethacin. We hypothesize that the local injury on the face of this patient predisposes a mechanism of central sensitization, resulting in trigeminal autonomic cephalgia. Relation between trigemino-autonomic cephalalgias and leprosy provides insights into craniofacial pain mechanisms.

Murine dendritic cells transcriptional modulation upon Paracoccidioides brasiliensis infection

Limited information is available regarding the modulation of genes involved in the innate host response to Paracoccidioides brasiliensis, the etiologic agent of paracoccidioidomycosis. Therefore, we sought to characterize, for the first time, the transcriptional profile of murine bone marrow-derived dendritic cells (DCs) at an early stage following their initial interaction with P. brasiliensis. DCs connect innate and adaptive immunity by recognizing invading pathogens and determining the type of effector T-cell that mediates an immune response. Gene expression profiles were analyzed using microarray and validated using real-time RT-PCR and protein secretion studies. A total of 299 genes were differentially expressed, many of which are involved in immunity, signal transduction, transcription and apoptosis. Genes encoding the cytokines IL-12 and TNF-α, along with the chemokines CCL22, CCL27 and CXCL10, were up-regulated, suggesting that P. brasiliensis induces a potent proinflammatory response in DCs. In contrast, pattern recognition receptor (PRR)-encoding genes, particularly those related to Toll-like receptors, were down-regulated or unchanged. This result prompted us to evaluate the expression profiles of dectin-1 and mannose receptor, two other important fungal PRRs that were not included in the microarray target cDNA sequences. Unlike the mannose receptor, the dectin-1 receptor gene was significantly induced, suggesting that this β-glucan receptor participates in the recognition of P. brasiliensis. We also used a receptor inhibition assay to evaluate the roles of these receptors in coordinating the expression of several immune-related genes in DCs upon fungal exposure. Altogether, our results provide an initial characterization of early host responses to P. brasiliensis and a basis for better understanding the infectious process of this important neglected pathogen.

Paracoccidioidomycosis is a systemic disease that has an important mortality and morbidity impact in Latin America, mainly affecting rural workers of Argentina, Colombia, Venezuela and Brazil. Upon host infection, one of the most important aspects contributing to disease outcome is the initial encounter of the Paracoccidioides brasiliensis fungus with dendritic cells. This phagocytic cell is specialized in decoding microbial information and triggering specific immune responses. Thus, using a molecular biology technique to examine the response of thousand of genes, we aimed to identify the ways in which murine dendritic cells interact with P. brasiliensis during an early time point following infection. This approach allowed us to recognize diverse modulated genes, in particular those associated with a proinflamatory response and fungal recognition. Our work provides an initial molecular characterization of early infection process and should promote further investigations into the innate host response to this important fungal pathogen.

Dendritic cells transfected with scFv from Mab 7.B12 mimicking original antigen gp43 induces protection against experimental Paracoccidioidomycosis

Paracoccidioidomycosis (PCM), endemic in Latin America, is a progressive systemic mycosis caused by Paracoccidioides brasiliensis (P. brasiliensis), which primarily attacks lung tissue. Dendritic cells (DCs) are able to initiate a response in naïve T cells, and they also participate in Th-cell education. Furthermore, these cells have been used for therapy in several disease models. Here we transfected DCs with a plasmid (pMAC/PS-scFv) encoding a single chain variable fragment (scFv) of an anti-Id antibody that is capable of mimicking gp43, the main antigenic component of P. brasiliensis. First, Balb/c mice were immunized subcutaneously with pMAC/PS-scFv and, after seven days, scFv protein was presented to the regional lymph nodes cells. Moreover, we showed that the DCs transfected with scFv were capable of efficiently activating proliferation of total lymph node cells and inducing a decrease in lung infection. Therefore, our results suggested that the use of scFv-transfected DCs may be a promising therapy in the paracoccidioidomycosis (PCM) model.

Phagocytosis, Production of Nitric Oxide and Pro-inflammatory Cytokines by Macrophages in the Presence of Dematiaceus Fungi that Causes Chromoblastomycosis

Chromoblastomycosis is characterized by the slow development of polymorphic skin lesions (nodules, verrucas, tumores, plaques and scar tissue). Inside the host, infectious propagules adhere to epithelial cells and differentiate into sclerotic forms, which effectively resist destruction by host effector cells and allow onset of chronic disease. A cellular immune response against fungi is essential to control infection. Amongst the cells of the immune system, macrophages play the most important role in controlling fungal growth. In this study, we show that the fungicidal characteristic of macrophages is dependent on the fungal species that causes chromoblastomycosis. We began by observing that the phagocytic index was higher for Fonsecaea pedrosoi and Rhinocladiella aquaspersa compared with that of other fungi. Complement-mediated phagocytosis was more important for Phialophora verrucosa and R. aquaspersa and was inhibited by mannan when F. pedrosoi and R. aquaspersa conidia were phagocytosed by macrophages. We showed that macrophages killed significantly only R. aquaspersa. We also found that the phagocytosis of fungi has functional consequences for macrophages as phagocytosis resulted in down-modulation of MHC-II and CD80 expression as well as in the inhibition of the basal liberation of NO. However, the inhibition of the basal liberation of NO nor the down-modulation of MHC and co-stimulatory molecules were observed in the presence of R. aquaspersa.

Regulation of T helper cell differentiation in vivo by GP43 from Paracoccidioides brasiliensis provided by different antigen-presenting cells

Paracoccidioidomycosis, endemic in Latin America, is a progressive systemic mycosis caused by Paracoccidioides brasiliensis. The infection can evolve into different clinical forms that are associated with various degrees of suppressed cell-mediated immunity. Assuming that the effector immune response is a consequence of the preferential activation of either Th1 or Th2 subsets, in the present work we evaluated whether the nature of antigen-presenting cells (APCs) can influence the Th1/Th2 balance in vivo. It was observed that the injection of mature dendritic cells (DCs), macrophages and B cells primed the mice and induced a proliferation of T cells in vitro. It was seen that DCs from resistant mice stimulated predominantly interleukin-2 (IL-2) and interferon-gamma (IFN-gamma), whereas macrophages activated IL-10, IL-4 and IFN-gamma-secreting T cells and B cells IL-4 and IL-10 only. Results presented here clearly demonstrate that DC drives the development of cells secreting Th1-derived cytokines, whereas B cells induce the differentiation of a Th2 phenotype in vivo.