Fascial entrapment neuropathy

Effectiveness of myofascial release for adults with chronic neck pain: a meta-analysis

BACKGROUND

Every second human will experience a phase of neck pain in their lifetime and a high rate of chronicity exists. Because of the complexity and multiple influencing factors, chronic pain conditions are associated with a long treatment and diagnostic process. This leads to a prolonged healing process and high costs.

OBJECTIVE

To evaluate the effect of myofascial release on the variables of pain and range of motion in patients with chronic neck pain.

METHOD

Selection criteria were set to create a search algorithm for a systematic search in the databases: PubMed, Google Scholar, EBM Reviews, Medline, CINAHL, PEDro, and Science Direct. The risk of bias and the methodological quality was analyzed with the PEDro scale.

RESULT

Ten randomized controlled trials, with 549 participants met the eligibility criteria. The methodological quality was ranked from good to excellent. The myofascial release showed a significant difference in pain (p =  0.03), rotation to the right (p =  0.05), and lateral flexion to the right (p =  0.04), compared to other treatment methods. No significant effect was found for improvements in pressure pain threshold.

CONCLUSION

Modest effects are observed in pain reduction, suggesting potential benefits of myofascial release in managing chronic neck pain. Further research with standardized protocols and direct comparisons to established therapies is crucial for a comprehensive understanding of myofascial release efficacy.

CONTRIBUTION OF THE PAPER

What does the meta-analysis add to the current literature.

Ultrasound-Guided Sciatic Nerve Hydrodissection Can Improve the Clinical Outcomes of Patients with Deep Gluteal Syndrome: A Case-Series Study

Deep gluteal syndrome (DGS) is caused by sciatic nerve entrapment. Because fascial entrapment neuropathies may occur in multiple locations, ultrasound-guided nerve hydrodissection is a key component of DGS treatment. In this study, we examined the clinical outcomes of patients with DGS undergoing ultrasound-guided sciatic nerve hydrodissection. A 10 mL mixture consisting of 5% dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve hydrodissection. Clinical outcomes were evaluated using Numeric Rating Scale (NRS) scores of pain, the proportion of patients with favorable outcomes (reduction of ≥50% in pain), the duration for which patients exhibited favorable outcomes (percentage of follow-up duration), and the occurrence of major complications and minor side effects. A total of 53 patients were consecutively included and followed up for 3 to 19 months. After the initial injection, the NRS scores significantly improved at 1 week, 1 month, 3 months, and the final follow-up. Specifically, 73.6%, 71.7%, 64.2%, and 62.3% of the patients exhibited favorable outcomes at 1 week, 1 month, 3 months, and the final follow-up, respectively. The median duration for which the patients exhibited favorable outcomes was 84.7% of the follow-up period. Three patients (5.7%) experienced transient dizziness and vomiting, which resolved without further treatment. No vessel or nerve puncture was observed. Overall, ultrasound-guided sciatic nerve hydrodissection is a safe procedure that mitigates the pain associated with DGS. To achieve favorable outcomes, three consecutive injections 3 weeks apart are required.

The effectiveness of nerve mechanical interface treatment for entrapment neuropathies in the limbs: A systematic review with metanalysis

BACKGROUND

Neurodynamic approach employs neural mobilization and mechanical nerve interface techniques. While published studies investigated the efficacy of neural mobilization, it is currently unknown whether manual treatment of the nerve mechanical interface is effective in the treatment of people with entrapment neuropathies.

OBJECTIVES

Assess the effectiveness of mechanical interface treatment, including joint and soft tissue techniques, on pain and function in people with peripheral entrapment neuropathies.

DESIGN

Intervention systematic review with metanalysis.

METHODS

the databases MEDLINE, CINAHL, AMED, APA PsycINFO, SPORTDiscus, PubMed and ScienceDirect were searched from their inception to October 2022. Randomized controlled trials investigating mechanical interface treatment in isolation in patients with peripheral entrapment neuropathies were included. Two independent reviewers performed study selection, data extraction and risk of bias assessment using the Cochrane RoB 2.0 tool. Certainty of evidence for each outcome was judged using the GRADE framework.

RESULTS

11 studies were included in the review, all investigating carpal tunnel syndrome (CTS). Due to high heterogeneity of interventions and comparators, only five studies were pooled in a random-effects meta-analysis. There was evidence of mechanical interface techniques being more effective in reducing pain than sham (MD -2.47 [-3.94;-0.99]) and similarly effective as neural mobilization (MD -0.22 [-0.76; 0.33]) in CTS, albeit with low to very low certainty in the results.

CONCLUSION

mechanical interface techniques are effective for improving pain and function in people with CTS. However, the marked heterogeneity of included interventions and comparators prevents clinical recommendation of specific treatments.

Ultrasound-guided nerve hydrodissection of cervical nerve roots for cervical radicular pain in patients with mild and moderate to severe stenosis: a retrospective cohort study

Because fascial entrapment neuropathy can occur in multiple locations, ultrasound-guided nerve hydrodissection has become a key component of the treatment of cervical radicular pain. In this paper, we propose a combination of injectates used for nerve hydrodissection of the cervical nerve roots and compare the clinical outcomes of this treatment among patients with different severities of stenosis. This is a retrospective cohort study designed to compare outcomes between patients with mild stenosis and moderate to severe stenosis. Forty-four patients with mild cervical stenosis and 30 patients with moderate to severe cervical stenosis were consecutively enrolled into two groups. A 10-mL mixture in a single level consisting of 5% in Dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve roots hydrodissection. The two groups were compared with regard to their numeric rating scales (NRS) of pain, proportion of patients who exhibited a favorable outcome (a reduction of pain ≥ 50%), duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects. The follow-up period ranged from 3 to 20 months. The NRS of both groups improved significantly by 1 week, 1 month, 3 months, and final follow-up after the initial injection. Differences in the groups' NRS, proportion of patients who exhibited a favorable outcome, duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects were nonsignificant. There were 4 patients (5.4%) experienced dizziness in that resolved without further treatment. Ultrasound-guided nerve hydrodissection of cervical nerve roots is a safe procedure that reduces pain associated with cervical radicular pain, even in patients with moderate to severe stenosis.

Mechanical Effects of a Specific Neurodynamic Mobilization of the Superficial Fibular Nerve: A Cadaveric Study

CONTEXT

A specific neurodynamic mobilization for the superficial fibular nerve (SFN) has been suggested in the reference literature for manual therapists to evaluate nerve mechanosensitivity in patients. However, no authors of biomechanical studies have examined the ability of this technique to produce nerve strain. Therefore, the mechanical specificity of this technique is not yet established.

OBJECTIVES

To test whether this examination and treatment technique produced nerve strain in the fresh frozen cadaver and the contribution of each motion to total longitudinal strain.

DESIGN

Controlled laboratory study.

SETTING

Laboratory.

MAIN OUTCOME MEASURE(S)

A differential variable reluctance transducer was inserted in 10 SFNs from 6 fresh cadavers to measure strain during the mobilization. A specific sequence of plantar flexion, ankle inversion, straight-leg raise position, and 30° of hip adduction was applied to the lower limb. The mobilization was repeated at 0°, 30°, 60°, and 90° of the straight-leg raise position to measure the effect of hip-flexion position.

RESULTS

Compared with a resting position, this neurodynamic mobilization produced a significant amount of strain in the SFN (7.93% ± 0.51%, P < .001). Plantar flexion (59.34% ± 25.82%) and ankle inversion (32.80% ± 21.41%) accounted for the biggest proportions of total strain during the mobilization. No difference was noted among different hip-flexion positions. Hip adduction did not significantly contribute to final strain (0.39% ± 10.42%, P > .05), although high variability among limbs existed.

CONCLUSIONS

Ankle motion should be considered the most important factor during neurodynamic assessment of the SFN for distal entrapment. These results suggest that this technique produces sufficient strain in the SFN and could therefore be evaluated in vivo for correlation with mechanosensitivity.

The Peripheral Nerve Surgeon's Role in the Management of Neuropathic Pain

Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.

Treatment of postsurgical trigeminal neuralgia with Fu's subcutaneous needling therapy resulted in prompt complete relief: Two case reports

RATIONALE

Trigeminal neuralgia is a recurrent unilateral transient electroshock-like pain. Fu's subcutaneous needling (FSN), used to treat the musculoskeletal problems, has not been reported in this field.

PATIENT CONCERNS

The pain extent of case 1 had no reduction after the previous microvascular decompression, the pain of case 2 relapsed 4 years after the microvascular decompression.

DIAGNOSES

Postsurgical trigeminal neuralgia.

INTERVENTIONS

FSN therapy was applied on the muscles around the neck and face area, which the myofascial trigger points were palpated in these muscles. The FSN needle was inserted into the subcutaneous layer and the needle tip was pointed toward the myofascial trigger point.

OUTCOMES

The following outcome measurements were observed before and after treatment, including numerical rating scale, Barrow Neurology Institute Pain Scale scores, Constant Face Pain Questionnaire scores, Brief Pain Inventory-Facial scores, Patient Global Impression of Change scores, and medication dosage. The follow-up surveys were made after 2 and 4 months respectively. The pain of Case 1 was significantly reduced after 7 times FSN treatments and the pain of Case 2 was even disappeared after 6 times FSN treatments.

LESSONS

This case report suggested that FSN can relieve postsurgical trigeminal neuralgia safely and effectively. Clinical randomized controlled studies are needed to be further conducted.

Ultrasound Imaging and Guidance for Cervical Myofascial Pain: A Narrative Review

Cervical myofascial pain is a very common clinical condition in the daily practice of musculoskeletal physicians. Physical examination is currently the cornerstone for evaluating the cervical muscles and identifying the eventual presence of myofascial trigger points. Herein, the role of ultrasound assessment in precisely localizing them is progressively mounting in the pertinent literature. Moreover, using ultrasound, not only the muscle tissue but also the fascial and neural elements can be accurately located/evaluated. Indeed, several potential pain generators, in addition to paraspinal muscles, can be involved in the clinical scenario of cervical myofascial pain syndrome. In this article, the authors extensively reviewed the sonographic approach for cervical myofascial pain in order to better diagnose or guide different procedures that can be performed in the clinical practice of musculoskeletal physicians.

Dorsal Root Ganglion Stimulation Lead Fracture Within the Superficial Fascial Layers in 4 Cases

We present 4 cases of dorsal root ganglion stimulation lead fracture. In these cases, the surgical technique involved (1) traversing fascial layers for placement of leads via a Tuohy needle in the upper low back, (2) subcutaneous tunneling from the implantable pulse generator site to the lead puncture site without dissecting below the superficial fascial plane at the puncture site, and (3) connection of the lead/extension with the generator. All fractures occurred adjacent to the original lead puncture site. These cases suggest lead entrapment within the membranous fascial plane, with tension on a thin lead, is a mechanism underlying lead fracture.

Fascial Manipulation Technique in the Conservative Management of Morton's Syndrome: A Pilot Study

Background and Objective: Morton’s syndrome (MS) is a common cause of neuropathic chronic forefoot pain, characterised by the development of a swelling of the common digital plantar nerve, whose aetiology is not fully known. There is currently no gold standard of treatment; nonoperative management commonly involves manual therapies, orthoses therapy and infiltrative techniques, while surgery is indicated after failure of conservative measures. The present preliminary study prospectively evaluates patients affected by MS treated by Fascial Manipulation technique (FM), a noninvasive manual therapy, focused on the release of the deep fascia, reducing its stiffness. Materials and Methods: Patients with clinical and sonographic diagnosis of MS with at least a 4-month history of neuropathic symptoms underwent a cycle of three weekly FM sessions. Clinical follow-up, including VAS and AOFAS scores, was performed 21 days (T1) and 3 months (T2) after treatment. Results: Nine patients, among 28 recruited initially, completed the manual therapy sessions and relative follow-up points. This noninvasive pain treatment led to significant improvement of VAS (p = 0.0034) and AOFAS scores (p = 0.0240) at the first follow-up (T1). At 3-month follow-up (T2), both scores decreased slightly, remaining however superior to the pre-treatment values. Only VAS was still significant (p = 0.0184). Conclusions: Despite the small size of the case series, this pilot study is unique in supporting Fascial Manipulation in the nonoperative treatment of MS. Further studies are needed with a large cohort of gender balanced patients to confirm the encouraging results obtained.

Peripheral Nerve Responses to Muscle Stretching: A Systematic Review

Stretching is commonly used to increase range of motion and flexibility. Therefore, investigations are usually oriented towards the muscle-tendon unit. Limited evidence exists regarding potential effects of stretching on peripheral nerves which lie within muscles. The objective of this investigation will be to elucidate the responses of peripheral nerves to stretching. A literature search was performed using the following databases: Scopus, NLM Pubmed and ScienceDirect. Studies regarding the effects of stretching protocols on responses of peripheral nerves were retrieved for investigation. The NHLBI tool was used for quality assessment. Outcomes included nerve stiffness, nerve displacement, pain pressure thresholds and resistive torque. A total of 10 studies were considered eligible and were included in this investigation. The quality assessment of the studies revealed an overall "fair to good" methodological quality across the included studies. All studies except for one involved healthy participants. High heterogeneity of stretching protocols was retrieved. As a consequence of stretching, nerve stiffness (-15.6%) and pain pressure thresholds (-1.9kg) increased. Nerve displacements on each movement plane for all the considered nerves and nerve deformation were also frequently observed. Peripheral nerve responses to muscle stretching include decreased nerve stiffness and increased pain pressure thresholds. Nerve displacement also frequently occurs. It is still unclear if reduced nerve displacement may lead to clinical outcomes. There is a lack of longitudinal studies regarding peripheral nerve adaptations to stretching.

Muscle Fascia Changes in Patients with Occipital Neuralgia, Headache, or Migraine

SUMMARY

In an ongoing effort to understand the pathogenesis of occipital neuralgia/headache/migraine, it is critical to describe the anatomical/tissue changes encountered during surgery. Greater occipital nerve anatomical studies mainly focus on the greater occipital nerve course through muscle/fascial planes and interaction with the occipital vessels. However, structural soft-tissue changes have not been described in detail. Anecdotally, trapezius fascia is thickened at the greater occipital nerve trigger site. This study further investigates this observation. Patients undergoing greater occipital nerve decompression surgery were enrolled prospectively in this observational study (n = 92). Tissue changes were recorded intraoperatively. The resulting data were examined. Trapezius fascia was more than 3 mm thick and appeared fibrotic in 86 patients (94 percent), whereas semispinalis muscle appeared normal in all subjects. The greater occipital nerve was macroscopically abnormal, defined as edematous, flattened, and discolored in 29 cases (32 percent). The occipital artery interacted significantly with the greater occipital nerve in 88 percent of cases. The authors conclude that the tissue structure is abnormal in patients undergoing greater occipital nerve decompression surgery. This is the first study that describes the prevalence of thickened and fibrotic appearing trapezius fascia at the occipital trigger site, a phenomenon encountered in the vast majority of patients (94 percent). This structural anomaly has a resemblance to thickened fascial tissues seen in other nerve compression syndromes, and could be related to microtrauma/overuse or actual trauma in the head and neck region.

Quantitative Evaluation of the Echo Intensity of Paraneural Area and Myofascial Structure around Median Nerve in Carpal Tunnel Syndrome

The aim of this study was to investigate whether the echo intensity (EI) of the paraneural area (PA), the median nerve (MN) at the carpal tunnel, the EI of the myofascial structure (MS) around MN, the ‘PA and MN’ at the mid-forearm, and the MN transversal displacement at both sites differs between persons with carpal tunnel syndrome (CTS) and control subjects. Methods: In total, 16 CTS patients and 16 controls, age- and gender-matched, were recruited. Cross-sectional ultrasound images of MN were obtained to evaluate the EI of the PA, the MN at carpal tunnel, the EI of MS, and the ‘PA and MN’ at the mid-forearm in a natural position, then images were taken after a whole-hand grasp movement, to evaluate MN transversal displacement. Inter-rater and intra-rater reliability in control, and differences in the EI and MN displacement between CTS and control, were analyzed. In addition, the correlations between ultrasound parameters and MN displacement were evaluated. Results: The quantitative EI of PA, MN, EI of MS, ‘PA and MN’ had high inter-rater and intra-rater reliability in the control. The EI of PA, MS and ‘PA and MN’ were significantly higher in CTS subjects (p < 0.01), whilst there was no significant difference in the EI of MN at the carpal tunnel. MN displacement was significantly decreased both at the carpal tunnel and the mid-forearm in CTS subjects (p < 0.01). In addition, there were negative correlations among the EI of PA (rs = −0.484, p = 0.004), EI of MS (rs = −0.479, p = 0.002), EI of ‘PA and MN’ (rs = −0.605, p < 0.001) and MN transversal displacement. Conclusions: The higher EI of PA and MS around MN in CTS may indicate greater fibrosis along the course of MN, reducing fascial adaptability, influencing the synergy and coordination of the MS, and increasing the shear stress between MS and MN, and it may further increase the abnormal pressure on the MN not only at the carpal tunnel, but also at the mid-forearm. These results may partly explain the role of PA and MS in CTS pathogenesis.