Reliability of assessment of upper trapezius morphology, its mechanical properties and blood flow in female patients with myofascial pain syndrome using ultrasonography

Superficial fascia displacement in cervical flexion: differentiating myofascial pain syndrome, a cross-sectional study

CONTEXT

Myofascial pain syndrome (MPS) is primarily characterized by myofascial trigger points related to fascial adhesions. MPS hinders fascial flexibility and mobility, leading to myofascial limitations, dysfunctional movement, and limitation of motion (LOM).

OBJECTIVES

This study determined the association of age, sex, type of work, symptom chronicity, symptom laterality, cervical LOM, altered direction of fascial displacement, and magnitude of superficial fascial displacement during active cervical flexion with the clinical diagnosis of MPS.

METHODS

A cross-sectional study selectively included MPS and non-MPS participants from different workplaces from January to October 2019. The MPS group exhibited clinical symptoms like tender spots, recognized pain patterns, and local twitch response upon palpation, often accompanied by cervical LOM. The non-MPS group lacked these symptoms, and those with certain pre-existing conditions or recent physiotherapy were not part of the study. Participants performed cervical active range of motion (AROM) while a sonographer recorded superficial fascial displacement utilizing ultrasound, which was later analyzed by three physiotherapists with the Tracker. Aiming for a multiple regression R-squared of 0.2, the target was 384 participants to account for a 20 % dropout, resulting in 307 participants after attrition. To explore the relationships between MPS and various factors, logistic regression models, rigorously tested for reliability and validity, were utilized.

RESULTS

In the study, there were 192 participants with MPS and 137 without MPS. The median ages were 33 years for the non-MPS group and 38 years for the MPS group. The adjusted model found significant links for sex (odds ratio [OR]=2.63, p<0.01), symptom chronicity (OR=8.28, p<0.01), and cervical LOM (OR=3.77, p=0.01). However, age and the presence of nodules/taut bands were not statistically significant (p>0.05). Also, the type of work, the direction of fascial displacement, and the difference in superficial fascial displacement during cervical flexion did not show a significant association with the clinical diagnosis of MPS (p>0.05). The adjusted model had a sensitivity of 73.80 % and a specificity of 81.34 %, correctly identifying 84.66 % of positive cases and 68.99 % of negative ones, resulting in an overall accuracy of 76.95 % in predicting MPS.

CONCLUSIONS

We provided an in-depth examination of MPS, identifying sex, duration of symptoms, and cervical LOM as significant predictive factors in its diagnosis. The study emphasizes the critical role of these variables in the accurate diagnosis of MPS, while delineating the comparatively minimal diagnostic value of other factors such as age, type of occupation, presence of nodules or taut bands, and variations in fascial displacement. This study underscores the imperative for further scholarly inquiry into the role of fascial involvement in musculoskeletal disorders, with the objective of enhancing both the theoretical understanding and diagnostic practices in this medical domain.

Comparison of Dry Needling and Cold-Spray-Stretching Treatments by Ultrasonography and Electrophysiology: Prospective, Randomized Controlled Trial

OBJECTIVES

To compare the efficacy of dry needling (DN) and cold-spray-stretching treatments using surface electromyography (sEMG) and ultrasound (US) in the treatment of patients with myofascial pain syndrome (MPS) with active trigger point (ATrP) in the upper trapezius muscle.

METHODS

This prospective randomized single-blind study included 60 MPS patients aged 18-65 years who have ATrP in the upper trapezius muscle. Patients were randomized into two treatment groups as DN and cold spray stretching. Both treatment groups received 1 treatment per week and totally 3 sessions. Evaluation parameters were pain level assessed by Numeric Rating Scale and algometer, neck range of motion angles, neck disability index (NDI). The effects of the treatments on ATrP were evaluated by sEMG and US histogram. All parameters were evaluated at the beginning of the treatment and at the end. Algometer and sEMG were performed also before and after the first and third sessions.

RESULTS

There was no significant difference between the two groups regarding demographic data. The mean age of the participants was 39.7 ± 11.6 years. Fifty-one patients were female. Significant improvement in terms of pain level, functionality, sEMG, and US histogram were achieved in both groups (P < .05). When comparing the two groups, algometer scores and the NDI score were statistically higher in the cold-spray-stretching group than in the DN group (P < .008 and P < .028, respectively).

CONCLUSION

Both treatment options should be preferred. The efficacy of both treatments was observed via sEMG and US histograms.

Assessment of the Performance of Ultrasonography for Detecting Myofascial Trigger Points

Needle electromyogram (EMG) research has suggested that endplate noise (EPN) is a characteristic of myofascial trigger points (MTrPs). Although several studies have observed MTrPs through ultrasonography, whether they are hyperechoic or hypoechoic in ultrasound images is still controversial. Therefore, this study determined the echogenicity of MTrP ultrasonography. In stage 1, the MTrP of rat masseter muscle was identified through palpation and marked. Needle EMG was performed to detect the presence of EPN. When EPN was detected, ultrasound scans and indwelling needles were used to identify the nodule with a different grayscale relative to that of its surrounding tissue, and the echogenicity of the identified MTrP was determined. In stage 2, these steps were reversed. An ultrasound scan was performed to detect the nodule at the marked site, and an EMG needle was inserted into the nodule to detect EPN. There were 178 recordings in each stage, obtained from 45 rats. The stage 1 results indicate that the MTrPs in ultrasound images were hypoechoic with a 100% sensitivity of assessment. In stage 2, the accuracy and precision of MTrP detection through ultrasonography were 89.9% and 89.2%, respectively. The results indicate that ultrasonography produces highly accurate and precise MTrP detection results.

Elastic Modulus of Suboccipital Muscles, Cervical Range of Motion, and Forward Head Posture in Cervicogenic Headache

Background

Although stiffness of neck muscles, the limitation of cervical range of motion (ROM), and forward head posture (FHP) are proposed as clinical characteristics of cervicogenic headache (CGH), adequate consistent data failed to support these characteristics.

Objective

This study aims to compare the elastic modulus of suboccipital muscles, cervical ROM, and FHP between individuals suffering from CGH and healthy controls.

Material and Methods

In this cross-sectional study, 20 individuals with a history of CGH and 20 normal individuals participated. Sonography images and a universal goniometer (UG) were used to assess elastic modulus and cervical ROM, respectively. In addition, FHP was assessed based on measuring craniovertebral angle (CVA) using a digital imaging technique and also the distance of anterior tragus of the ear with the vertical line passed from anterior of lateral malleolus according to the Kendall and McCreary method.

Results

Elastic modulus of suboccipital muscles in the CGH group was significantly higher than that of the normal group (P=0.008). The two groups were not significantly different in terms of FHP. Moreover, ROM of cervical extension (P=0.035), right rotation (P=0.046), and left rotation (P=0.018) showed a significant reduction in the CGH group compared to the control group.

Conclusion

Suboccipital muscles are stiffer and ROM of cervical rotation and extension is smaller in CGH patients than the healthy controls, but FHP is not different between the groups, leading to diagnosing CGH and treatment.

Viscoelasticity in trapezius myofascial pain syndrome: quantitative assessment using Real-Time Shear-Wave Elastography

OBJECTIVE

To investigate the differences in the viscoelastic properties between normal trapezius muscles and those in patients with trapezius myofascial pain syndrome (MPS) using real-time shear-wave elastography (SWE).

MATERIALS AND METHODS

This study included 31 patients with trapezius MPS and 31 volunteers. Sixty-one trapezius muscles (41 and 20 on the affected and non-affected side, respectively) of patients with MPS and 62 normal trapezius muscles in volunteers were assessed. Conventional ultrasonic parameters, including skeletal muscle thickness, resistance index (RI), and mean shear wave velocity (SWVmean) of trapezius muscles, were obtained in the seated position with the shoulders and neck relaxed. The daily neck leaning time (unit:hours) of all participants was obtained using a questionnaire.

RESULTS

Ultrasound showed no statistically significant differences in thickness or RI of the trapezius muscles of the affected and non-affected sides in MPS patients versus normal trapezius muscles (p = 0.976 and 0.106, respectively). In contrast, the SWVmean of trapezius muscles in patients with MPS was significantly higher than that of normal trapezius muscles in both the affected and non-affected sides (4.41 ± 1.02 m/s vs. 3.35 ± 0.79 m/s, p < 0.001; 4.05 ± 0.63 m/s vs. 3.35 ± 0.79 m/s, p = 0.002). There was no significant difference between the SWVmean of the trapezius muscles on the affected and non-affected sides in patients with MPS (4.41 ± 1.02 m/s vs. 4.05 ± 0.63 m/s, p = 0.225). Correlation analysis showed that daily neck forward time was positively correlated with the SWVmean of the trapezius muscles on the affected and non-affected sides in patients with MPS (r = 0.635, p < 0.001; r = 0.576, p = 0.008).

CONCLUSION

SWE can quantitatively evaluate stiffness of trapezius muscles in patients with trapezius MPS. The stiffness of both affected and non-affected trapezius muscles increased in patients with trapezius MPS, and the degree of increase positively correlated with the time of cervical forward leaning.

Effects of Dry Needling on Biomechanical Properties of the Myofascial Trigger Points Measured by Myotonometry: A Randomized Controlled Trial

OBJECTIVE

The purpose of the present study was to examine the effect of dry needling (DN) on the biomechanical properties of a latent medial myofascial trigger point (MTrP) of the soleus muscle compared with an adjacent point within the taut band (TB) measured by myotonometry.

METHODS

Fifty asymptomatic volunteers were randomly assigned to an intervention group (n = 26) or control group (n = 24). One session of DN was performed in every group as follows: 10 needle insertions into the MTrP area (intervention group) or TB area (control group). Myotonometric measurements (frequency, decrement, and stiffness) were performed at baseline (pre-intervention) and after the intervention (post-intervention) in both locations (MTrP and TB areas).

RESULTS

The results showed that stiffness outcome significantly decreased with a large effect size after DN in the MTrP when measured in the MTrP location (P = .002; d = 0.928) but not when measured in the TB location. In contrast, no significant changes were observed in any location when the TB was needled (P > .05).

CONCLUSIONS

The findings suggest that only DN into the MTrP area was effective in decreasing stiffness outcome, therefore a specific puncture was needed to modify myofascial muscle stiffness.

A sonographic comparison of the effect of dry needling and ischemic compression on the active trigger point of the sternocleidomastoid muscle associated with cervicogenic headache: A randomized trial

BACKGROUND

Cervicogenic headache (CeH) is among the common types of headache which has an undesirable influence on the quality of life. The myofascial trigger point (MTrP) within the sternocleidomastoid (SCM) muscle is one of the most important causes of CeH.

OBJECTIVE

The purpose of this study was to compare the effect of dry needling (DN) and ischemic compression (IC) on the headache symptoms as well as MTrP-related features in subjects with CeH originating from MTrPs of the SCM muscle using a sonographic method.

METHODS

A total of 29 female subjects aged 35.34 ± 12.19 on average with a clinical diagnosis of CeH originating from MTrP in the SCM muscle were randomly divided into the DN, IC, and control groups. Both DN and IC groups received 4 treatment sessions. Headache intensity, duration, frequency, MTrP elastic modulus, MTrP area, and pressure pain threshold (PPT) were assessed 2 weeks before and after treatments.

RESULTS

In both DN and IC groups, a significant improvement was found in the headache intensity, duration, frequency, PPT, and MTrP area (P< 0.05). No significant differences were observed between DN and IC (P> 0.05). Pearson correlation revealed a significant correlation between headache intensity and the MTrP elastic modulus (P< 0.05).

CONCLUSIONS

Both interventions could reduce headache symptoms, PPT, and MTrP area. Neither intervention was found to be superior to the other in short-term follow-up. IC may be preferred since it has fewer unwanted side effects compared to DN. Based on the data, it may be concluded that some MTrP biomechanical features such as stiffness may influence the produced headache symptoms.

Interrater and Intrarater Reliability and Minimum Detectable Change of Ultrasound for Active Myofascial Trigger Points in Upper Trapezius Muscle in Individuals With Shoulder Pain

OBJECTIVE

We sought to investigate the interrater and intrarater reliability of ultrasound and the minimum detectable change (MDC) for the trigger points (TrPs) active in the upper trapezius (UT) muscle in individuals with shoulder pain.

METHODS

Forty individuals with shoulder pain were investigated for the presence of active TrPs in the UT muscle by means of ultrasound for the parameters of gray scale, muscle thickness of UT muscle at rest, and contraction and area of TrPs. The intrarater reliability was performed on 2 days, and interrater reliability on the same day. For the gray scale, the reliability was evaluated using the kappa coefficient (κ), while the other parameters were measured by the intraclass correlation coefficient (ICC), standard error of measurement (SEM), and MDC.

RESULTS

For the gray scale, the intrarater agreement was almost perfect (κ = 1.00) and the interrater agreement was substantial (κ = 0.75). The intrarater and interrater reliability were excellent for most of the parameters, except for the area of TrPs (intrarater: ICC = 0.71, substantial; interrater: ICC = 0.52, substantial). The MDC for intrarater reliability varied between 0.04 and 0.05 (SEM% between 2.4% and 38.87%), and that for interrater reliability ranged from 0.05 to 0.07 (SEM% between 3.18% and 55.10%), with a higher value for area.

CONCLUSION

Parameters such as gray scale, resting muscle thickness, and muscle contraction of the UT muscle, obtained through ultrasound, showed excellent intrarater and interrater reliability with low SEM%. The intrarater and interrater reliability for the area deserves a caveat regarding their use.

Relationship between trapezius muscle hardness and transverse cervical artery flow in association with neck and upper-back stiffness

Neck and upper-back stiffness is a common discomfort encountered occasionally in daily life among otherwise healthy subjects. The pathogenesis of this condition could be attributable to increased tension in muscles such as the trapezius muscle (TM). The transverse cervical artery (TCA) is one of the feeding arteries for the TM, and TCA flow is reportedly related to symptoms of neck and upper-back stiffness. This study quantitatively investigated relationships between TM hardness and TCA hemodynamics as evaluated on Doppler sonography. Questionnaires regarding neck and upper-back stiffness, muscle hardness measurements obtained using a muscle hardness meter and examinations of TCA hemodynamics using Doppler sonography were performed on 55 healthy young adults (25 males, 30 females; mean age, 22 ± 2 years). Subjects displaying neck and upper-back stiffness actually exhibited high muscle hardness (median, 14.0; interquartile range (IQR), 12.9-18.0) compared to those without the symptom (median, 12.0; IQR, 9.9-14.0; p = .002). Peak systolic velocity in the TCA on Doppler sonography was lower in subjects with the symptom (median, 65.1 cm/s; IQR 59.6-72.5 cm/s) than in those without the symptom (median, 72.5 cm/s; IQR 66.5-84.2 cm/s; p = .012). Resistive index in the TCA was high (r²  = .605, p = .014) with increasing TM hardness, particularly among male subjects with the symptom. The present study suggests that high resistance and low blood flow velocity in the TCA could be closely associated with the underlying pathogenesis of neck and upper-back stiffness.

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.

Vaginal discharge caused by lymphatic malformation identified by lymphoscintigraphy combined with T2-weighted magnetic resonance imaging

Prepubertal vaginal discharge is most commonly caused by vulvovaginitis and is rarely caused by lymphatic malformations, resulting in chylous vaginal discharge. The diagnosis of chylous vaginal discharge remains a challenge because of a knowledge gap. We describe a 12-year-old girl with intermittent vaginal discharge for 10 years. Although we found a high signal in the vagina on T2-weighted magnetic resonance imaging (MRI), the final diagnosis, vaginal lymphatic leakage, was established on lymphoscintigraphy. Lymphatic leakage in the vagina on lymphoscintigraphy was the key imaging feature of chylous vaginal discharge in this patient. Moreover, diffuse radioactivity was found in the abdomen and thorax on lymphoscintigraphy, which indicated the multiple cystic lymphatic malformations and intestinal lymphangiectasia combined with T2-weighted MRI. Thus, T2-weighted MRI could be used in combination with lymphoscintigraphy to simply identify chylous vaginal discharge.

Stiffness and echogenicity: Development of a stiffness-echogenicity matrix for clinical problem solving

The assessment of soft tissue stiffness is important to evaluate many neuromusculoskeletal conditions. Several tools have been proposed for the assessment of stiffness, but ultrasonography appears to be most practical. The reflection of ultrasound waves as it travels through tissue enables assessment of tissue echogenicity, which is influenced by the characteristics of the sound wave as well as the characteristics of the tissue through which it passes, such as the amount of fat and fibrous tissue. However, tissue stiffness is not directly proportional to its echogenicity. Hence evaluation of echogenicity, as a stand-alone technique, is inadequate to describe its mechanical properties. The aim of this manuscript is to present a method of combining echogenicity evaluation by ultrasound and stiffness evaluation by palpation to better describe the mechanical properties of muscle using a stiffness-echogenicity matrix.

Ultrasound imaging for sarcopenia, spasticity and painful muscle syndromes

PURPOSE OF REVIEW

On the basis of its various advantages and the relevant awareness of physicians, ultrasound imaging has overwhelmingly taken its place in the scientific arena. This is true both from the side of daily clinical applications and also from the side of research. Yet, ultrasound provides real-time (diagnostic) imaging and (interventional) guidance for a wide spectrum of muscle disorders. In this regard, this review aims to discuss the potential/actual utility of ultrasound imaging in particular muscle disorders, that is, sarcopenia, spasticity and fibromyalgia/myofascial pain syndrome.

RECENT FINDINGS

Due to the aging population worldwide and the importance of functionality in the older population, mounting interest has been given to the diagnosis and management of sarcopenia in the recent literature. Likewise, several articles started to report that ultrasound imaging can be used conveniently and effectively in the early diagnosis and quantification of sarcopenia.For spasticity, aside from ultrasound-guided botulinum toxin injections, intriguing attention has been paid to sonographic evaluation of muscle architecture, echogenicity and elasticity in the follow-up of these chronic conditions.As regards painful muscle syndromes, quantitative ultrasound techniques have been shown to detect statistically significant differences between healthy controls and patients with myofascial pain syndrome.

SUMMARY

Ultrasound imaging seems to be a promising tool that indisputably deserves further research in the management of a wide range of muscle disorders. VIDEO ABSTRACT: http://links.lww.com/COSPC/A17.

Novel method to measure active myofascial trigger point stiffness using ultrasound imaging

INTRODUCTION

Myofascial trigger points (MTrPs) are one of the most common and important causes of musculoskeletal pain. Ultrasound is a useful modality in examining musculoskeletal disorders. By applying compressive stress and observing changes in ultrasound images, the elastic modulus (Young's modulus) can be calculated. Our objective was to develop a novel method to distinguish MTrPs from normal tissues.

METHODS

A total of 29 subjects with MTrP in the sternocleidomastoid muscle were assessed. A force gauge was attached to a transducer to obtain stress levels. To obtain strain, images were recorded in both with stress and without stress states. By dividing the stress level by the measured strain, the elastic modulus was determined.

RESULTS

Elastic modulus in MTrPs and the normal part of the muscle were measured to be 13379.57 ± 1069.75Pa and 7078.24 ± 482.92Pa, respectively (P = 0.001). This indicated that MTrPs were stiffer than normal parts of the muscle.

CONCLUSION

This study presents a new method for the quantitative measurement of the elastic modulus of MTrP, thereby distinguishing MTrPs from normal adjacent muscular tissue, with more simplicity and lower cost, compared to other ultrasound methods.