A critical evaluation of the trigger point phenomenon

An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.

Diagnostic confounders of chronic widespread pain: not always fibromyalgia

Although chronic widespread pain is the defining feature of fibromyalgia, a myriad of other conditions may present with similar pain complaint leading to misdiagnosis. Conditions that may mimic fibromyalgia may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. In this review, we examine these various conditions that should be considered in a differential diagnosis and provide direction that will help the clinician differentiate these conditions from fibromyalgia.

Introduction:

Chronic widespread pain (CWP) is the defining feature of fibromyalgia (FM), a worldwide prevalent condition. Chronic widespread pain is, however, not pathognomonic of FM, and other conditions may present similarly with CWP, requiring consideration of a differential diagnosis.

Objectives:

To conduct a literature search to identify medical conditions that may mimic FM and have highlighted features that may differentiate these various conditions from FM.

Methods:

A comprehensive literature search from 1990 through September 2016 was conducted to identify conditions characterized by CWP.

Results:

Conditions that may mimic FM may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. Characteristics pertaining to the most commonly identified confounding diagnoses within each category are discussed; clues to enable clinical differentiation from FM are presented; and steps towards a diagnostic algorithm for mimicking conditions are presented.

Conclusion:

Although the most likely reason for a complaint of CWP is FM, this pain complaint can be a harbinger of illness other than FM, prompting consideration of a differential diagnosis. This review should sensitize physicians to a broad spectrum of conditions that can mimic FM.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report.

METHODS

This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper.

RESULTS

A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

T4 syndrome - A distinct theoretical concept or elusive clinical entity? A case report

T4 syndrome has existed as a clinical concept for more than three decades and it has been identified as a source of upper extremity (UE) symptoms. This case report explores the clinical reasoning in the diagnoses and management of a patient with symptoms consistent with T4-type syndrome and critically discusses the concept of T4 syndrome using recent research to help explain the clinical presentation. Manual therapy treatment focused on stimulation of the sympathetic ganglia, decreasing local upper thoracic pain and UE referral pattern noted during passive examination. The successful outcomes included immediate and lasting symptom relief after upper thoracic spinal manipulation. Although treatment has been based on the theory that mechanical thoracic dysfunction can produce sympathetic nervous system (SNS) referred pain, the role the sympathetic reflexes potentially plays on the referral symptoms to the UE presently remains unclear.

The short-term effects of trigger point therapy, stretching and medicine ball exercises on accuracy and back swing hip turn in elite, male golfers - A randomised controlled trial

OBJECTIVES

This study aimed to compare the effect of myofascial trigger point therapy (MTPT) and stretching, MTPT and medicine ball exercises, and no intervention, on hip flexor length (HFL), golf swing biomechanics and performance in elite, male golfers.

DESIGN

Single blind, randomised controlled trial with two experimental groups (stretch group: MTPT and stretching; and the ball group: MTPT, a single stretch and medicine ball exercises) and one control group (no intervention).

SETTING

Professional golf academy.

PARTICIPANTS

One hundred, elite, male golfers aged 16-25 years.

MAIN OUTCOME MEASURES

HFL, 3D biomechanical analysis of the golf swing, club head speed (CHS), smash ratio, accuracy and distance at baseline and after the interventions.

RESULTS

Backswing hip turn (BSHT) improved in the ball group relative to the control group (p = 0.0248). Accuracy in the ball group and the stretch group improved relative to the control group (Fisher's exact = 0.016).

CONCLUSIONS

Other performance parameters such as: smash ratio, distance and CHS were not compromised by either intervention. This study advocates the use of MTPT combined with medicine ball exercises over MTPT combined with stretching in the treatment of golfers with shortened hip flexors - even immediately preceding a tournament.

Physical Therapy in the Treatment of Central Pain Mechanisms for Female Sexual Pain

INTRODUCTION

The complexity of female sexual pain requires an interdisciplinary approach. Physical therapists trained in pelvic health conditions are well positioned to be active members of an interdisciplinary team addressing the assessment and treatment of female sexual pain. Changes within physical therapy practice in the last ten years have resulted in significant utilization of pelvic floor muscle relaxation and manual therapy techniques to address a variety of pelvic pain conditions, including female sexual pain. However, sexual pain is a complex issue giving credence to the necessity of addressing all of the drivers of the pain experience- biological, psychological and social.

AIM

This review aims to reconcile current pain science with a plan for integrating a biopsychosocial approach into the evaluation and subsequent treatment for female sexual pain for physical therapists.

METHODS

A literature review of the important components of skilled physical therapy interventions is presented including the physical examination, pain biology education, cognitive behavioral influences in treatment design, motivational interviewing as an adjunct to empathetic practice, and the integration of non-threatening movement and mindfulness into treatment.

MAIN OUTCOME MEASURE

A single case study is used to demonstrate the biopsychosocial framework utilized in this approach.

RESULTS

Appropriate measures for assessing psychosocial factors are readily available and inform a reasoned approach for physical therapy design that addresses both peripheral and central pain mechanisms. Decades of research support the integration of a biopsychosocial approach in the treatment of complex pain, including female sexual pain.

CONCLUSION

It is reasonable for physical therapists to utilize evidence based strategies such as CBT, pain biology education, Mindfulness Based Stress Reduction (MBSR), yoga and imagery based exercises to address the biopsychosocial components of female sexual pain.

Subjective and clinical assessment criteria suggestive for five clinical patterns discernible in nonspecific neck pain patients. A Delphi-survey of clinical experts

BACKGROUND

Nonspecific neck pain patients form a heterogeneous group with different musculoskeletal impairments. Classifying nonspecific neck pain patients into subgroups based on clinical characteristics might lead to more comprehensive diagnoses and can guide effective management.

OBJECTIVE

To establish consensus among a group of experts regarding the clinical criteria suggestive of a clinical dominance of 'articular', 'myofascial', 'neural', 'central' and 'sensorimotor control' dysfunction patterns distinguishable in patients with nonspecific neck pain.

STUDY DESIGN

Delphi study.

METHODS

A focus group with 10 academic experts was organized to elaborate on the different dysfunction patterns discernible in neck pain patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 distinct dysfunction patterns resulting from the focus group.

RESULTS

A total of 21 musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating neck pain patients completed the 3-round Delphi-survey. Respectively, 33 (response rate, 100.0%), 27 (81.8%) and 21 (63.6%) respondents replied to rounds 1, 2 and 3. Eighteen 'articular', 16 'myofascial', 20 'neural', 18 'central' and 10 'sensorimotor control' clinical indicators reached a predefined ≥80% consensus level.

CONCLUSION

These indicators suggestive of a clinical dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns may help clinicians to assess and diagnose patients with nonspecific neck pain. Future validity testing is needed to determine how these criteria may help to improve the outcome of physical therapy interventions in nonspecific neck pain patients.

The immediate effect of multiple mechanical impulses on electromyography and pressure pain threshold of lumbar latent trigger points: an experimental study

BACKGROUND

Myofascial pain is a common syndrome, which has not been studied extensively in the low back. Despite a variety of manual and instrument assisted interventions available, little work has targeted the possible effects of fast mechanical impulses on myofascial trigger points (MTrPs) on its sensitivity and electrical activity. The purpose of this experimental study was to quantify the immediate effect of one session of mechanical impulses to lumbar latent MTrPs and to normal muscle tissue with pressure pain threshold (PPT) and surface electromyography (sEMG) as outcome measures.

METHODS

During the autumn of 2009, in 41 asymptomatic subjects between 17-40 years of age the lumbar musculature was searched for a latent MTrP by a trained clinician. Using 3 disposable pre-gelled electrodes bilaterally, sEMG was recorded continuously from muscle containing either latent or no MTrP. Both the trigger point group and control group received the intervention and were blinded to group allocation. The immediate effects of mechanical impulses were assessed by sEMG and PPT before and after intervention using Wilcoxon matched-pairs signed-ranks test, Mann-Whitney U test and paired t-tests.

RESULTS

The PPT increased significantly across both groups (p < 0.01) after intervention. The proportionate increase (14.6 %) was comparable in both MTrP and control groups. The electrical activity on the MTrP side was not significantly higher in the MTrP group compared to the contralateral side. The decrease of resting electrical activity after intervention was significant in the MTrP group on the side of the latent MTrP (P = 0.001) as well as the contralateral side (p=0.022), and not significant in the control group on either side (p=0.33 and p=0.93).

CONCLUSION

In this study, the immediate effect of one session of mechanical impulses was associated with a significant increase in PPT for both groups and a significant decrease in the resting electrical activity of the lumbar muscles only in the MTrP group. It is unknown if these effects have clinical significance.

Treatment of myofascial pain syndrome with lidocaine injection and physical therapy, alone or in combination: a single blind, randomized, controlled clinical trial

BACKGROUND

Myofascial pain syndrome (MPS) of the shoulder girdle and cervical region is a common musculoskeletal problem that is often chronic or recurrent. Physical therapy (PT) and lidocaine injections (LI) are two treatments with demonstrated effectiveness compared to a control group, however little is known about their combined value. The objective of this study was to determine whether LI into trigger points combined with a PT program would be more effective than each separate treatment alone in improving pain, function, and quality of life in a group of patients with MPS of the shoulder girdle and cervical region.

METHODS

A single-blind, randomized, controlled clinical trial (RCT) was conducted with three parallel groups in the Departments of Physical Medicine and Rehabilitation of two urban hospitals in Medellin, Colombia. One hundred and twenty seven patients with shoulder girdle MPS for more than 6 weeks and pain greater than 40 mm on the visual analog scale (VAS) were assigned to 1 of 3 intervention groups: PT, LI, or the combination of both (PT + LI). The primary outcome was VAS pain rating at 1-month post-treatment. The secondary outcomes included VAS pain rating at 3 months, and, at both 1 and 3 months post-treatment: (a) function, evaluated by hand-back maneuver and the hand-mouth maneuver, (b) quality of life, as measured by sub-scales of the Short Form - 36 (SF-36), and (c) depressive symptoms, as measured by the Patient Health Questionnaire - 9 (PHQ-9). Independent t-tests were used to compare outcomes between groups at 1 month and 3 months post-treatment.

RESULTS

In the per protocol analysis, there were no significant intergroup differences in VAS at 1 month PT + LI, 40.8 [25.3] vs. PT, 37.8 [21.9], p = 0.560 and vs. LI, 44.2 [24.9], p = 0.545. There were also no differences between groups on secondary outcomes except that the PT and PT + LI groups had higher right upper limb hand-back maneuver scores compared to the LI alone group at both 1 and 3 months (p = 0.013 and p = 0.016 respectively).

CONCLUSIONS

The results of this RCT showed that no differences in pain ratings were observed between the individual treatments (PT or LI) compared to the combined treatment of PT and LI. In general, no difference in primary or secondary outcomes was observed between treatments.

TRIAL REGISTRATION

NTC01250184 November 27, 2010.

Quantification of Myofascial Taut Bands

OBJECTIVE

To assess the correlation of clinician-identified myofascial taut bands with their presence and characteristics on magnetic resonance elastography (MRE) imaging.

DESIGN

Cross-sectional study.

SETTING

A magnetic resonance imaging (MRI) research laboratory.

PARTICIPANTS

A convenience sample of adults (N=65; 45 women, 20 men) identified by skilled musculoskeletal physicians as having upper trapezius myofascial pain-associated taut bands.

INTERVENTIONS

Subjects had their taut bands outlined and were positioned within a 1.5T MRI machine. Shear waves were induced with a pneumatic transducer located over the belly of the involved muscle. Wave propagation was visualized with MRE images across a vibration cycle. Imaging data were assessed independently by 2 skilled MRE interpreters.

MAIN OUTCOME MEASURES

The primary outcome measure was the determination of the intra- and interrater reliabilities of MRE taut band identification and their correlation with clinician identification of band presence. Secondary outcomes consisted of the elucidation of the physical characteristics of taut bands and their surrounding muscle tissue.

RESULTS

MRE intra- and interrater reliability was excellent, with kappa coefficients and 95% confidence intervals (CIs) of .86 (.68-1.00) and .93 (.79-1.00), respectively. Stiffness in MRE-identified taut bands was elevated at a mean ± SD of 11.5±2.4 kPa and fell to 5.8±0.9 kPa in surrounding muscle tissue (P<.001); muscular tone in trapezius muscles without a taut band was relatively uniform at 6.6±2.1 kPa. Agreement between the physicians and the MRE raters, however, was relatively poor (63.1%; 95% CI, 50.2%-74.7%).

CONCLUSIONS

Our findings suggest that while clinicians may overestimate, and current MRE techniques may underestimate, the presence of taut bands, these bands do exist, can be assessed quantitatively, and do represent localized areas of increased muscle stiffness.

Muscles and their role in episodic tension-type headache: implications for treatment

BACKGROUND AND OBJECTIVE

Tension-type headache (TTH) imposes a heavy burden on the global population but remains incompletely understood and poorly managed.

DATABASES AND DATA TREATMENT

Here, we review current knowledge of peripheral factors involved in the mechanism of TTH and make recommendations for the treatment of episodic TTH based on these.

RESULTS

Peripheral activation or sensitization of myofascial nociceptors is most probably involved in the development of muscle pain and the acute episode of TTH. Repetitive episodes of muscle pain may sensitize the central nervous system resulting in progression of TTH to the chronic form. Thus, muscular factors may be responsible not only for the acute headache episode but also for chronification of the disorder. Simple analgesics and non-steroidal anti-inflammatory drugs are the mainstays of management of individual headache episodes. Ibuprofen 400 mg and aspirin 1000 mg are recommended as drugs of first choice based on treatment effect, safety profile and costs. Non-pharmacological therapies include electromyographic biofeedback, physiotherapy and muscle relaxation therapy. Future studies should aim to identify the triggers of peripheral nociception and how to avoid peripheral and central sensitization. There is a need for more effective, faster acting drugs for acute TTH.

CONCLUSION

Muscular factors play an important role in episodic TTH. Ibuprofen 400 mg and aspirin 1000 mg are recommended as drugs of first choice.