Myofascial pain syndrome treatments

Evaluating the Effectiveness of Radiofrequency Therapy and Manual Pelvic Fascial Release in Treating Myofascial Pelvic Pain

INTRODUCTION AND HYPOTHESIS

Myofascial pelvic pain (MFPP), characterized by sensitive trigger points in the pelvic floor muscles, leads to chronic pain and affects various aspects of life. Despite the availability of different treatment modalities, there is limited comparative research on their effectiveness. This study compares radiofrequency (RF) therapy and myofascial manual therapy (MMT) in treating MFPP. We aimed to evaluate pelvic floor muscle strength changes, clinical symptoms, and patient comfort during treatment.

METHODS

The study involved 176 participants, divided equally into RF and MMT groups. We assessed pelvic floor pain using the Visual Analogue Scale (VAS), muscle strength using the Modified Oxford Scale (MOS) and surface electromyography (sEMG), clinical symptom improvement through questionnaires, and patient discomfort during treatment.

RESULTS

Both RF and MMT groups significantly reduced pelvic floor and paraurethral muscle pain (VAS scores, p < 0.001). RF treatment significantly decreased vaginal laxity in its group (p < 0.001), with no notable change in the MMT group (p = 0.818). RF therapy also resulted in greater patient comfort than MMT (p < 0.001). Although both treatments improved clinical symptoms, there was no significant difference between the two (p = 0.692). MOS scores and pelvic floor sEMG values showed no significant differences between the groups before and after treatment (p > 0.05).

CONCLUSIONS

Both RF and MMT effectively alleviate pelvic floor pain and improve clinical symptoms in MFPP patients. RF therapy, however, offers additional benefits in reducing vaginal laxity and enhancing treatment comfort.

Myofascial pain - A major player in musculoskeletal pain

Myofascial pain is a soft tissue pain syndrome with local and referred musculoskeletal pain arising from trigger points. Myofascial pain and myofascial pain syndromes are among some of the most common acute and chronic pain conditions. Myofascial pain can exist independently of other pain generators or can coexist with or is secondary to other acute and chronic painful musculoskeletal conditions. Myofascial pain is most effectively treated with a multimodal treatment plan including injection therapy (known as trigger point injections, physical therapy, postural or ergonomic correction, and treatment of underlying musculoskeletal pain generators. The objectives of this review are to outline the prevalence of myofascial pain, describe the known pathophysiology of myofascial pain and trigger points, discuss the clinical presentation of myofascial pain, and present evidence-based best practices for pharmacologic, non-pharmacologic, and interventional treatments for myofascial pain.

Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play

For nonsurgical musculoskeletal (MSK) injuries in athletes, image-guided percutaneous intervention may aid in recovery and decrease return to play (RTP) time. These interventions fall into two major categories: to reduce inflammation (and therefore alleviate pain) or to promote healing. This review describes the risks and benefits of the various percutaneous interventions in MSK athletic injury and surveys the literature regarding the implication of these interventions on RTP.

Effect of Mirror Therapy on Post-Needling Pain Following Deep Dry Needling of Myofascial Trigger Point in Lateral Elbow Pain: Prospective Controlled Pilot Trial

Background: This prospective randomized, controlled pilot trial to explore the immediate effect of adding Mirror Visual Feedback Therapy on pain sensitivity and motor performance among subjects suffering from post-needling pain diagnosed as Lateral Elbow Pain. Methods: A total of 49 participants (23 female, 26 male) were enrolled and randomly allocated to either the experimental group, which received Deep Dry Needling in the m. Brachioradialis, Ischemic Compression, Cold Spray, Stretching, and Mirror Visual Feedback Therapy (n = 25), or a control group without Mirror Visual Feedback Therapy (n = 24). Pre- and post-treatment evaluations included assessments of post-needling pain intensity, pressure pain threshold, two-point discrimination threshold, and maximum hand grip strength. Results: Intergroup analysis revealed a statistically significant reduction in post-needling pain intensity favoring the experimental group (U = 188.00, p = 0.034). Additionally, intragroup analysis showed significant improvements in post-needling pain intensity (MD = 0.400, SEM = 0.271, W = 137.00, p = 0.047) and pressure pain threshold (MD = 0.148 Kg/cm2, SEM = 0.038, W = 262.00, p < 0.001) within the experimental group following the intervention. Conclusions: These findings suggest a potential benefit of integrating Mirror Visual Feedback Therapy into treatment protocols for individuals with Lateral Elbow Pain experiencing post-needling discomfort. Further research is necessary to fully elucidate the clinical implications of these findings.

An overview of myofascial pain syndrome with a focus on trigger point injection

ABSTRACT

Myofascial pain syndrome (MPS) is a very common condition, with an estimated lifetime prevalence of 85% in the general population. MPS is commonly underdiagnosed or misdiagnosed due to the lack of standardized diagnostic criteria and the symptoms' overlap with those of other musculoskeletal pain conditions. The most notable and bothersome feature of MPS is the presence of myofascial trigger points (MTrPs), hypersensitive areas of muscle commonly characterized as knots, nodules, or bumps that cause strain and pain with and oftentimes without stimulation. A low-risk, low-cost procedure, trigger point injection (TPI) is the gold standard for MPS treatment, and NPs can perform the procedure in an outpatient practice setting. Through administration of TPIs and use of other treatment modalities, primary care NPs can significantly impact the quality of life for those patients affected by acute and chronic MPS. This article aims to educate primary care NPs on MPS diagnosis and provide an overview of treatment options, with a focus on TPI use and administration for MPS relief.

Preclinical efficacy of TZG in myofascial pain syndrome by impairing PI3K-RAC2 signaling-mediated neutrophil extracellular traps

Tianhe Zhuifeng Gao (TZG) shows a satisfying therapeutic efficacy in treating arthromyodynia, which shares similar etiology to myofascial pain syndrome (MPS). We herein aim to explore whether TZG could be a potential prescription for MPS therapy. An MPS rat model was successfully established presenting with reduced pain thresholds, abnormal local switch responses, etc., which was effectively reversed by TZG treatment externally. A transcriptome sequencing based on the active MTrPs samples of rats, combined with network analysis revealed that TZG might ameliorate the progression of MPS by impairing neutrophil extracellular traps (NETs) release through inhibiting PI3K-RAC2 signaling to reduce NADPH oxidase-originated ROS. Experimentally, the expression levels of inducers, biomarkers of NETs formation and vessel injury, and p-PI3K, p-P47, and RAC2 proteins were all significantly up-regulated in affected tissues, which were markedly reversed by TZG. Our results not only shed light into broadening the clinical indications of TZG, but benefit MPS therapy.

Comparison of the effectiveness of instrument-assisted soft tissue mobilization and extracorporeal shock wave therapy in myofascial pain syndrome

Background/aim

To compare the effectiveness of instrument-assisted soft tissue mobilization (IASTM) and extracorporeal shock wave therapy (ESWT) used in myofascial pain syndrome (MPS) and to determine whether they are superior to conservative treatment (CT).

Materials and methods

A total of 42 female patients (aged 18-60 years) diagnosed with MPS were enrolled and randomly assigned to either the CT (n = 14), CT+IASTM (n = 14), or CT+ESWT group (n = 14). All of the groups received treatment for 3 weeks (CT: 5 sessions per week, 15 sessions in total, ESWT and IASTM: 2 sessions per week, 6 sessions in total). Neck stretching exercises were given to all of the patients as a home program. The pain intensity of the patients was determined using the visual analog scale (VAS). The pressure pain threshold (PPT) was measured with an algometer. Cervical joint range of motion (ROM) was measured with a cervical ROM (CROM) device. Pain, cervical disability, quality of life, and sleep disturbances were evaluated with the Neck Outcome Score (NOOS). Depression and anxiety parameters were evaluated with the Hospital Anxiety and Depression Scale (HADS). Evaluations were made before treatment and 3 days after the last treatment session.

Results

The CT+IASTM group was more successful than the other groups in terms of pain intensity, PPT, and improvements in the ROM parameters (p < 0.05). No significant difference was found between the NOOS and HADS scores of the groups when the posttreatment changes were compared to pretreatment (p > 0.05).

Conclusions

All 3 of these treatments can be used to alleviate the negative effects of MPS. IASTM treatment can be preferred primarily in the creation of combined treatment programs for patients with ROM limitations and low PPTs.

Botulinum Toxin Injections as a Treatment of Refractory Vulvodynia in Adolescents: A Case Series

BACKGROUND

Vulvodynia involves vulvar discomfort that occurs in the absence of an identifiable cause. Because vulvodynia is often accompanied by myofascial pain and pelvic floor tension, transvaginal botulinum toxin (BT) injection into the pelvic floor has been proposed as a possible treatment.

METHODS

Retrospective case series RESULTS: Three adolescents with vulvodynia had a suboptimal response to treatment with several interventions, including neuromodulators (oral and topical), tricyclic antidepressants (oral and topical), and pelvic floor physical therapy. Subsequently, these patients underwent BT injections to the pelvic floor as treatment with varying responses.

CONCLUSION

In select adolescent patients with vulvodynia, transvaginal BT injection into the pelvic floor can be an effective treatment. Further studies are needed to assess the optimal dosing, frequency, and sites of BT injections in the treatment of vulvodynia in pediatric and adolescent patients.

Bibliometric and Visual Analysis in the Field of Dry Needling for Myofascial Pain Syndrome from 2000 to 2022

Background

Evidence has shown that dry needling (DN) is effective for myofascial pain syndrome (MPS). However, bibliometrics has rarely been used to analyze the literature related to DN for MPS. The purpose of this study is to provide a systematic overview of global frontiers and research hotspots of DN in the treatment of MPS from 2000 to 2022.

Methods

A search was conducted on Web of Science Core Collection (WoS CC) for literature on DN for MPS from 2000 to 2022. Based on the basic information provided by WoS CC, CiteSpace software was used to conduct bibliometric analysis of the countries, institutions, categories, journals, authors, references and keywords involved in this topic.

Results

A total of 458 papers were obtained, with the number of publications increasing over time. Journal of Bodywork and Movement Therapies (31) was the most productive journal based on the number of publications, while Arch Phys Med Rehab (329) was the most co-cited journal. The most productive countries and institutions were USA (112) and Universidad Rey Juan Carlos (39), respectively. Fernandez-de-las-penas, Cesar has the highest number of publications (24) and Simons DG, who was an author with the highest number of citations (250). The article published by Gattie et al (co-citations: 65), and Mejuto-Vazquez et al (centrality: 0.36) were the most representative and symbolic. Based on the co-cited literature and keywords, myofascial trigger point, research methods, and acupuncture were the hot research topics and trends in the field.

Conclusion

The current status and trends in clinical research of DN for MPS are revealed according to the results of this bibliometric study, which may facilitate researchers to identify hot topics and new directions for future research.

Creation of myofascial pain syndrome-like muscle by artificial electrical stimulation and stretching treatment

BACKGROUND

Myofascial pain syndrome（MPS）is a common chronic pain disorder characterized by muscle hardness, low extensibility, restriction of range of motion (ROM)　and pain with trigger point (TP). Eccentric contraction has been used in past animal studies of MPS. However, clinical experience suggests that concentric contraction is also involved in MPS formation.

NEW METHODS

In this study, we adopted artificial electrical stimulation to create artificial concentric contraction (ACC) in rat gastrocnemius muscle. After ACC, muscle hardness, torsion and range of motion (ROM) were compared between before ACC, after ACC, and stretching group. To clarify the association with pain, the expression of pERK in DRG were analyzed.

COMPARISON TO EXISTING METHODS

Previous animal studies have created MPS models by inducing eccentric contractions in muscles. In this study, full tetanus contraction of the gastrocnemius muscle was achieved via tibial nerve stimulation. This method substituted muscle contraction due to abnormal excitation.

RESULTS

We found that artificial abnormal contraction (ACC) induced muscle hardness and ROM restriction. The pERK expression in DRG was increased by ACC. Analysis of muscle tissue sections revealed a meandeling structure in muscle fibers. The stretching treatment improved these indicators. These results were similar to feature of the MPS muscles.

CONCLUSIONS

The ACC caused by artificial electrical stimulation leads to the characteristic of MPS in rat gastrocnemius muscle. This ACC model can be one of the useful options for MPS analysis.

Kinesio Taping as a Therapeutic Tool for Masticatory Myofascial Pain Syndrome-An Insight View

Myofascial pain syndrome (MPS) is thought to stem from masticatory muscle hypersensitivity. Masticatory myofascial pain syndrome (MMPS) is characterized by multiple trigger points (MTrPs), also known as hyperirritable points, in taut bands of affected muscles, regional muscle pain, or referred pain to nearby maxillofacial areas like teeth, masticatory muscles or the temporomandibular joint (TMJ). Muscle stiffness, reduced range of motion, muscle weakening without atrophy, and autonomic symptoms may accompany regional discomfort. Multiple treatments have been utilized to reduce trigger points and mandibular function restrictions. As a result of these incapacitating symptoms, MMPS can significantly impair many elements of quality of life. The application of Kinesio tape (KT) is a non-invasive method of treating dormant myofascial trigger points. Utilizing the body's innate capacity for self-repair, this technique entails taping specific regions of the skin. KT alleviates discomfort, decreases swelling and inflammation, enhances or suppresses motor function in the muscles, stimulates proprioception, promotes lymphatic drainage, stimulates blood flow, and expedites tissue recovery. However, studies conducted to assess its effects have frequently yielded contradictory results. To the best of our knowledge, just a few research has looked into the therapeutic effects of KT on MMPS. The purpose of this review is to determine the efficacy of KT as a therapeutic tool for regular treatment or as an adjunct to existing therapy for MMPS based on the evidence presented in this review. To establish KT as a reliable independent treatment option, additional research is necessary to confirm the efficacy of KT techniques and applications, specifically randomized clinical trials.

Research Trends of Acupuncture Therapy on Myofascial Pain Syndrome from 2000 to 2022: A Bibliometric Analysis

Background

Acupuncture has been widely used to relieve myofascial pain syndromes (MPS) in many countries. However, the bibliometric analysis of the global application of acupuncture for MPS remains unknown.

Purpose

The present study aims to evaluate the research trends and hot spots of acupuncture for MPS.

Methods

Literatures about acupuncture for MPS from 2000 to 2022 were obtained from the Web of Science. CiteSpace (6.1.R3) was used to analyze the number of publications, countries, institutions, authors, cited journals, cited authors, cited references and keywords.

Results

A total of 403 records were included in the final analysis. The total number of publications increased but with some fluctuations. The Pain was the most cited journals. The most productive country and institution were USA, and China Medicine University, respectively. Liwei Chou was the most prolific author, and Simons DG ranked first in the cited author. In the ranking of frequency and centrality in cited references, the first article was published by Tough EA and Simons DG, respectively. The keyword of "acupuncture" ranked first in frequency, "double blind" ranked first in centrality. "Meta-analysis" was the keyword with the strongest citation burst. There were three hot topics in this field, including "the clinical feature of MPS", "measure of intervention" and "research method". The mechanism of acupuncture on MPS was one of the main research directions.

Conclusion

This study reveals that acupuncture was more and more acceptable, while the cooperation between different countries, institutions and authors should be strengthened. The researches of therapeutic effect and mechanism were the main research directions. More high-quality clinical trials are needed to confirm the therapeutic effect of acupuncture for MPS, and more studies to unify the acupuncture parameters such as frequency, duration, and intensity. More basic studies are needed to elucidate the precise mechanism of acupuncture for MPS.

Masticatory Myofascial Pain Disorders

Masticatory myofascial pain disorders (MMPD) are a common group of orofacial pain conditions affecting the muscles of mastication, with headache and cervical disorders as well as chronic widespread pain and psychosocial disorders being common comorbid conditions. As their pathophysiology is multifactorial in nature, a multimodal and interdisciplinary approach should be considered. Overall treatment goals include decreasing pain and disability, increasing mandibular range of motion, and improving quality of life. This article describes a complex case exhibiting common characteristics of MMPD while additionally reviewing the literature on classification, pathophysiology, and evidence-based treatment planning.

Preliminary evidence of safety and effectiveness of Loxoprofen Sodium Cataplasm combined with physiotherapy for myofascial pain syndrome treatment: A randomized controlled pilot clinical trial

BACKGROUND

Myofascial pain syndrome (MPS) is one of the most common causes of chronic skeletal muscle pain, which is closely related to skeletal muscle myofascial trigger point (MTRP). Since there is no first-line treatment for MPS, we investigated Loxoprofen Sodium Cataplasm combined with physiotherapy as a non-invasive therapy in patients at different levels to a protocol with superior efficacy that is safe and easy to promote. Moreover, this treatment could represent an alternative therapeutic strategy for low-income patients to a safer, more convenient, and more economical treatment scheme.

METHODS

A randomized clinical study was aimed at evaluating the safety and efficacy of Loxoprofen Sodium Cataplasm combined with physiotherapy in patients diagnosed with MPS in the pain clinic. We screened 100 patients with MPS, and using a computer-generated random allocation sequence, we stratified patients in a ratio of 2:1:1:1 (A: B: C: D) to one of the four treatment groups. Group A received Loxoprofen Sodium Cataplasm combined with extracorporeal shock wave therapy (ESWT) and transcutaneous electrical nerve stimulation (TENS). Group B received Loxoprofen Sodium Cataplasm alone. Group C received physiotherapy alone. Group D received Flurbiprofen Cataplasm combined with physiotherapy. After 2 weeks of treatment, the overall efficiency and secondary assessment indicators, including visual analog scale (VAS) scores, chronic soft tissue injury (CSTI) scores, Oswestry Disability Index (ODI) scores, or Northwick Park Neck Pain Questionnaire (NPQ) scores, were evaluated before and after treatment to analyze the difference in efficacy of each group.

RESULTS

All groups were well tolerated with no reported adverse events. Significant treatment differences in the change from baseline in overall efficiency (primary efficacy endpoint) (P = 0.0078) were observed in subjects of groups A and C.

CONCLUSION

Showing valuable data of efficacy in primary and secondary endpoints, Loxoprofen Sodium Cataplasm combined with physiotherapy is superior in the treatment of MPS.

TRIAL REGISTRATION NUMBER

https://www.chictr.org.cn/ (ChiCTR2100054756).

Comparison of the effectiveness between dry needling with and without needle retention in myofascial trigger points in upper trapezius muscle: A randomized comparative trial

BACKGROUND

Dry needling (DN) is commonly used to treat myofascial trigger points (MTrPs).

OBJECTIVE

To compare the effect between DN with and without needle retention in the treatment of MTrPs in the upper trapezius muscle.

METHODS

Fifty-four patients who had active MTrPs in the upper trapezius muscle were randomly allocated into the DN group or the DN with retention group. The DN group received DN only, while the DN with retention group received DN with needle retention for 30 minutes. The visual analogue scale (VAS) and pressure pain threshold (PPT) were recorded both before and after 7 and 14 days of the treatment sessions.

RESULTS

Both groups showed a significant decrease of the VAS at 7 and 14 days (mean difference DN group -53.0, DN with retention group -57.0, p< 0.001). The PPT was also significantly improved in both groups (mean difference DN group 109.8 kPa, DN with retention group 132.3 kPa, p< 0.001). However, there were no significant differences in the VAS or PPT between the groups.

CONCLUSIONS

Both DN and DN with retention had significant improvement of pain intensity in the treatment of MTrPs in the upper trapezius muscle at 14 days. However, pain reduction was not significantly different between the interventions.

The Specifics of Non-specific Low Back Pain: Re-evaluating the Current Paradigm to Improve Patient Outcomes

Low back pain (LBP) is the leading cause of pain and debility worldwide and the most frequent reason for work-related disability. Global expenditures related to LBP are staggering and amount to billions of dollars each year in the United States alone. Yet, despite the considerable healthcare resources consumed, the care provided to patients with LBP has regularly been cited as both ineffective and exorbitant. Among the myriad reasons for this suboptimal care, the current approach to evaluation and management of patients with LBP is a likely contributor and is hitherto un-investigated. Following the current methodology, over 90% of patients with LBP are provided with no specific diagnosis, are managed inconsistently, and receive no express preventative care. We believed that this approach added costs and promoted chronic unresolved pain and disability. This narrative review highlights problems with the current methodology, proposes a novel concept for categorizing patients with LBP, and recommends strategies for improvement. Stratifying patients according to the etiology, in lieu of the prospects for morbidity, the strategy proposed in this article may help ascertain the cause of patient's LBP early, consolidate treatments, permit timely preventative measures, and, as a result, may improve patient outcomes.

Trigger Point Injection as a Rare Cause of Ischemic Stroke: A Case Report

INTRODUCTION

Myofascial pain syndrome is a painful local or regional disease caused by myofascial trigger points. Trigger point injection (TPI) is a frequently used method for the treatment of myofascial pain. Major complications associated with TPI have rarely been reported in the literature.

CASE REPORT

A 24-year-old woman, without medical history of any disease, was diagnosed with myofascial syndrome based on the presence of long-standing neck and right arm pain, and TPI with lidocaine was applied to the right trapezius region. During the procedure, blurred vision and loss of strength in the left arm occurred. Magnetic resonance and computed tomography imaging of the brain revealed findings that were consistent with an ischemic stroke in the right capsular interna and right occipital region.

CONCLUSION

The reported patient is the first in the literature who suffered from ischemic stroke after TPI. The use of ultrasound for injections into the neck muscles could avoid serious complications.

Effects of Repeated Injection of 1% Lidocaine vs. Radial Extracorporeal Shock Wave Therapy for Treating Myofascial Trigger Points: A Randomized Controlled Trial

Background and Objectives: This study tested the hypothesis that treatment of myofascial trigger points (MTrPs) in the upper trapezius muscle (UTM) with repeated injection of 1% lidocaine results in better alleviation of muscular stiffness and soreness as well as improved metabolism in the hypercontracted MTrP area than treatment with radial extracorporeal shock wave therapy (rESWT). Materials and Methods: A single-blinded, prospective, randomized controlled trial was conducted on patients suffering from MTrPs in the UTM. Thirty patients were treated with repeated injection of 2 mL of 1% lidocaine (three injections; one injection per week). Another 30 patients were treated with rESWT (three treatment sessions; one treatment session per week; 2000 radial extracorporeal shock waves per treatment session; positive energy flux density = 0.10 mJ/mm2). The primary outcome measure was pain severity using the VAS score. The secondary outcome measures included muscle elasticity index, pressure pain threshold and neck disability index. Evaluation was performed at baseline (T1), 15−30 min after the first treatment in order to register immediate treatment effects (T2), before the second treatment (i.e., one week after baseline) (T3) and one week after the third treatment (i.e., four weeks after baseline) (T4). Results: There were no statistically significant differences in the primary and secondary outcome measures between the patients in the lidocaine arm and the patients in the rESWT arm at T1 and T4. Within the arms, the mean differences of all outcomes were statistically significant (p < 0.001) when comparing the data obtained at T1 with the data obtained at T3 and the data obtained at T4. Conclusions: The results of this pilot study suggest that the use of rESWT in patients with MTrPs in the UTM is safe and leads to reduced pain and improved muscle elasticity, pressure pain threshold and neck disability index, without adverse effects. Larger trials are necessary to verify this. Clinicians should consider rESWT instead of injections of lidocaine in the treatment of MTrPs in the UTM.

Ultrasound-Guided Erector Spinae Plane Block and Trapezius Muscle Injection for Myofascial Pain Syndrome

OBJECTIVE

There were two goals to this study: the first goal was to research the analgesic effectiveness of erector spinae plane block (ESPB) added to the treatment after trapezius muscle injection (TMI) and the second was to investigate whether repeated TMI increases the analgesic effect in myofascial pain syndrome (MPS).

METHODS

Sixty patients with a diagnosis of MPS were randomized into two groups. The TMI group (n = 30) received ultrasound-guided (USG) TMI with 5 mL of 0.25% bupivacaine two times, with a 1-week interval in between. The ESPB group (n = 30) received USG TMI with 5 mL of 0.25% bupivacaine in the first week and USG ESPB with 20 mL of 0.125% bupivacaine in the second week. The pain severity of the patients was evaluated using the visual analog scale (VAS). The data obtained before (week 0) and after (weeks 1, 2, 3, and 4) the injections were statistically compared between the groups.

RESULTS

In both groups, the mean VAS score decreased in the first week compared to the mean pretreatment score (p < .001). When the VAS scores were compared between the first and second weeks, a decrease was observed in both groups (p < .001), but it was more evident in the ESPB group. Compared to previous weeks, there was no significant difference in VAS scores at the third and fourth weeks.

CONCLUSIONS

The analgesic effect of repeated TMI for MPS was superior to a single injection, but ESPB combined with TMI provided more effective analgesia than repeated TMI.

Ultrasound-Guided Musculoskeletal Injections

Musculoskeletal injections serve a variety of diagnostic and therapeutic purposes, with ultrasonography (US) guidance having many advantages: no ionizing radiation, real-time guidance, high spatial resolution, excellent soft tissue contrast, and the ability to identify and avoid critical structures. Sonography can be cost effective and afford flexibility in resource-constrained settings. This article describes US-guided musculoskeletal injections relevant to many radiology practices and provides experience-based suggestions. Structures covered include multiple joints (shoulder, hip), bursae (iliopsoas, subacromial-subdeltoid, greater trochanteric), peripheral nerves (sciatic, radial), and tendon sheaths (posterior tibial, peroneal, flexor hallucis longus, Achilles, long head of the biceps). Trigger point and similar targeted steroid injections, as well as calcific tendinopathy barbotage, are also described.

Acupuncture-like versus conventional transcutaneous electrical nerve stimulation in the management of active myofascial trigger points: A randomized controlled trial

PURPOSE

Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. The transcutaneous electrical nerve stimulation (TENS) is a non-expensive, safe, feasible modality, used recently for the treatment of MPS with promising but limited results. The purpose of this study was to determine the efficacy of acupuncture-like TENS (AL-TENS) vs conventional TENS (C-TENS) in the treatment of active myofascial trigger points.

METHODS

This randomized controlled trial study was carried out with 60 consecutive patients with active trapezius trigger points referred to Physical Medicine and Rehabilitation Clinic. Participants randomly assigned to receive AL-TENS, C-TENS or sham TENS (S-TENS). The Visual Analogue Scale (VAS), Pressure Pain Thresholds (PPTs), and neck range of motion (ROM) were measured at baseline, after the first treatment sessions, after the final treatment session, and 3 months after the end of the last treatment session. Patients function was evaluated by Disabilities of the Arm, Shoulder, and Hand (DASH) at baseline, after the final treatment sessions, and 3 months after the end of intervention.

RESULTS

The interaction effect of time and group was significantly different when evaluating VAS (df = 4.65, F = 2.50, p = 0.038) and DASH (df = 2.63, F = 7.25, p < 0.001) in favor of active groups, as well as neck total lateral bending in favor of AL-TENS group compared other two groups (df = 4.16, F = 5.23, p = 0.001). Both VAS and DASH improved significantly at all follow-ups in AL-TENS and C-TENS groups. Of note, significant immediate improvement in all outcomes was observed only with AL-TENS.

CONCLUSIONS

According to the present study, both AL-TENS and C-TENS were superior to placebo in pain reduction and functional improvement. Although both TENS techniques have similar efficiency on pain reduction, functional and pain perception improvement, the AL-TENS was the superior approach when evaluating neck lateral bending ROM.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Retrospective study of the clinical effect of incobotulinumtoxinA for the management of myofascial pain syndrome in refractory patients

The aim was to evaluate the effectiveness and safety of IncobotulinumtoxinA (IncoA) for the management of myofascial pain syndrome (MPS) in refractory patients. This single-center, observational, retrospective study includes 37 patients. The pain reduction was 4.7 points (95%CI: 5.6 to -3.8) from baseline to one-month post-injection (using a 10-point visual analogue scale). Only 18.9% experienced mild adverse events. In conclusion, IncoA is an effective and safe alternative for the treatment of MPS in refractory patients.

Effectiveness of pregabalin treatment for trigger points in patients with comorbid myofascial pain syndrome and fibromyalgia syndrome: a randomized controlled trial

AIM OF THE STUDY

Myofascial pain syndrome (MPS) is a common problem in the general population. MPS should not be a local/peripheral painful syndrome and considered to be a syndrome of central sensitivity. We aimed to investigate the effect of pregabalin in patients with MPS in this study.

MATERIALS AND METHODS

We randomized 40 patients into two groups, and 17 patients per group completed the study. Female patients in group I received pregabalin and exercise therapy, whereas those in group II received exercise therapy alone. All patients were evaluated as follows: for pain by visual analog scale (VAS); trigger-point pressure pain threshold-(PPT) by algometry; neuropathic pain using the Douleur Neuropathique en 4 Questions (DN4) and quality of life with the Short Form-36 (SF36). Evaluations were performed pre-treatment and at the end of the first and third months of treatment. Clinical trial ID: NCT04600037, retrospectively registered 20/10/2020.

RESULTS

In group I, significant improvements were observed in VAS, trigger-point-PPT, physical component summary-SF-36, at the first and third months. In group II, statistically significant improvements were observed in VAS, trigger-point-PPT after the first and third months. Group I showed statistically better improvements in VAS, trigger points-PPT, physical component summary-SF36 compared with group II by the third month.

CONCLUSION

Pregabalin treatment is effective for controlling trigger points. Pregabalin treatment is also more effective than exercise treatment at improving quality of life in patients with MPS.

A physiatrist's understanding and application of the current literature on chronic pelvic pain: a narrative review

Understanding the complex, multifactorial nature of chronic pelvic pain can help physicians determine the pain's etiology and thus refer specialists to include in the multidisciplinary treatment required.

Chronic pelvic pain (CPP) is a highly prevalent condition which is underdiagnosed and poorly understood. The purpose of this review is to outline the various aspects of the nature of CPP, including its etiologies, clinical presentation, and nonoperative treatment options. For data collection, a PubMed search was conducted using indexing terms such as chronic pelvic pain and pelvic pain. Literature reviews and studies focusing on etiologies, clinical presentation, and/or the diagnosis of CPP were compiled for review by a team of 3 physiatrists. Studies investigating conservative treatments, medications, and interventional procedures for CPP and related conditions with comparable etiologies were also included. Of the 502 articles retrieved, 116 were deemed suitable by the team for this study. Although CPP is a complex, multifaceted condition, a particular susceptibility to nociceptive stimuli was demonstrated as an underlying theme in its evolution. There are many treatment options currently used; however, more robust evidence, such as randomized controlled trials, are needed before creating comprehensive guidelines for treating CPP.

The effects of Biofreeze and superficial heat on masticatory myofascial pain syndrome

Purpose:

This study aims to assess the influence of superficial heat and Biofreeze on pain, mouth opening (mm), and quality of life in patients with masticatory myofascial pain syndrome (MPS).

Materials and methods:

52 patients with MPS were included in the study. They were randomly divided into two groups. Patients in the Biofreeze group (n = 26) applied 3.5% menthol gel to the masseter and temporal muscles twice a day for seven days, while the other group applied superficial heat. Baseline, 7th, and 21st days of VAS, mouth opening (mm), and Oral Health Impact Profile-14 (OHIP-14) scores of the patients were evaluated statistically.

Results:

The mouth opening increased by 4.27 ± 3.80 mm in the Biofreeze group and 2.58 ± 2.16 mm in the superficial heat group. In each group, a significant decrease in VAS and OHIP-14 scores was observed on the 7th day compared to the baseline values (p<0.001). There was no statistically significant difference between the two applications on myofascial pain, mouth opening (mm), and OHIP-14 total score variables. The favorable effects of both applications on these parameters were limited to the duration of use.

Conclusion:

Biofreeze and superficial heat in MPS were found to increase the quality of life, but the limited effectiveness of these applications underlines the importance of the underlying factors.

Comparison of the Effects of Physiologic Saline Interfascial and Lidocaine Trigger Point Injections in Treatment of Myofascial Pain Syndrome: A Double-Blind Randomized Controlled Trial

Objective

To compare the effects of physiological saline interfascial and lidocaine trigger point injections in the treatment of myofascial pain syndrome (MPS).

Design

Double-blind randomized controlled study.

Setting

Department of Rehabilitation Medicine.

Participants

Eighty patients (N=80; 15 men, 65 women; mean age, 40.4±10.9y) with MPS in the upper trapezius muscle.

Interventions

Patients were randomly assigned to 1 of 2 groups: group 1 (n=40) received ultrasound-guided interfascial injection with physiological saline, and group 2 (n=40) underwent ultrasound-guided trigger point injection with lidocaine.

Main Outcome Measures

The primary outcome was pain scores measured by the visual analog scale (VAS). Secondary outcomes included cervical range of motion (ROM) and adverse effects of the procedure. The outcomes were assessed before treatment and 10 minutes, 2 weeks, and 4 weeks after treatment.

Results

Lidocaine trigger point injection showed higher VAS score improvement at 10 minutes after the procedure (P=.037). However, there was no statistically significant difference at other follow-up points. Pain scores significantly decreased at 10 minutes, 2 weeks, and 4 weeks from baseline in both groups. Cervical ROM increased significantly over time in some directions without significant differences between the groups. There were no serious adverse effects in this study.

Conclusion

Physiologic saline interfascial and lidocaine trigger point injections effectively decreased MPS pain in the upper trapezius muscle at 2 and 4 weeks after treatment. However, lidocaine trigger point injection demonstrated better pain improvement at 10 minutes after treatment.

Fascial therapy, strength exercises and taping in soccer players with recurrent ankle sprains: A randomized controlled trial

INTRODUCTION

Recurrent ankle sprains are common in soccer players, characterized by restricted range of motion, pain, and decreased proprioception, strength, and postural control. The objective was to evaluate the effectiveness of a fascial therapy and strength training program, combined with kinesiotaping, in improving ankle range of motion, pain, strength and stability in footballers with recurrent sprains.

METHOD

A simple blind randomized clinical trial was conducted on soccer players. Thirty-six federated footballers were recruited and randomized to the two study groups. The experimental group received an intervention using myofascial techniques applied to the subastragaline joint, eccentric training with an isoinertial device and neuromuscular taping. The control group was administered an intervention using myofascial techniques on the subastragaline joint and eccentric training with an isoinertial device. The results were recorded for all players at baseline, after 4 weeks of intervention, and at the end of the 4-week follow-up period.

RESULTS

Subsequent to intervention and follow-up, we found statistically significant improvements in the experimental group in ankle mobility, strength and stability. The control group exhibited improvements in all study variables. No differences in the improvement of variables were found based on the allocation of athletes to one group or another.

CONCLUSION

The combination of fascial therapy and eccentric strength training with an isoinertial device improves ankle mobility, strength and stability in footballers with recurrent ankle sprains. The use of taping techniques failed to provide a greater improvement of the study variables when combined with manual therapy and strength techniques.

Expert consensus on the diagnosis and treatment of myofascial pain syndrome

Myofascial pain syndrome (MPS) is characterized by myofascial trigger points and fascial constrictions. At present, domestic and foreign scholars have not reached a consensus on the etiology and pathogenesis of MPS. Due to the lack of specific laboratory indicators and imaging evidence, there is no unified diagnostic criteria for MPS, making it easy to confuse with other diseases. The Chinese Association for the Study of Pain organized domestic experts to formulate this Chinese Pain Specialist Consensus on the diagnosis and treatment of MPS. This article reviews relevant domestic and foreign literature on the definition, epidemiology, pathogenesis, clinical manifestation, diagnostic criteria and treatments of MPS. The consensus is intended to normalize the diagnosis and treatment of MPS and be used by first-line doctors, including pain physicians to manage patients with MPS.

Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain

Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39–45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient’s recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.

The effect of the ischaemic compression technique on pain and functionality in temporomandibular disorders: A randomised clinical trial

BACKGROUND

Interventions addressing pain and impaired functionality in individuals with temporomandibular disorders (TMDs) are needed.

OBJECTIVE

To compare the effects of 4 weeks of exercise combined with ischaemic compression and exercise alone in patients with TMDs.

METHODS

Fifty patients who were diagnosed with TMDs were randomised into Group 1 (exercise combined with ischaemic compression technique) (n = 25) or Group 2 (exercise alone) (n = 25). Both groups performed 4 weeks of Rocabado's exercise and 3 weeks of postural exercise, while Group 1 received ischaemic compression to the masseter muscle for a total of 3 sessions in addition to exercise. A ruler was used to assess range of motion (ROM) (painless mouth opening (PMO), maximum mouth opening, maximum assisted mouth opening (MAMO), left lateral movement and right lateral movement), the visual analogue scale and graded chronic pain scale were used to assess pain, an algometer was used to determine the pain pressure threshold (PPT), and the 8-item jaw functional limitation scale was used to assess, functionality. The assessments were performed at baseline, at week 1 and at week 4.

RESULTS

The participants in Group 1 exhibited larger PMO (F = 5.26, P = .02) and MAMO values (F = 6.71, P = .01) than did the patients in Group 2 at week 1. The effect size was small for MAMO (ES = 0.27) and moderate for PMO (ES = 0.51). However, there were no significant differences in any other outcomes between groups at week 1 or 4.

CONCLUSION

In summary, this randomised controlled trial indicates that exercise combined with ICT and exercise alone have similar effects on ROM, pain, the PPT and functionality in patients with TMDs.

Anatomical Study of the Innervation of the Masseter Muscle and Its Correlation with Myofascial Trigger Points

Background and Purpose

Myofascial pain syndrome (MPS) is widely prevalent in the general population; some reports estimate its prevalence ranges from 9 to 85%. Among the different locations where MPS may arise, pain related to the masseter muscle is referred as masticatory myofascial pain. MPS is characterized by myofascial trigger points (MTPs), which represent tender anatomical areas of a muscle where painful symptoms are elicited whenever stimulated. Previous publications have found MTPs to coincide with neuromuscular junctions at the motor end plate, at the innervation zone (IZ). Our study aimed to describe the innervation of the masseter muscle and relate it to clinically described myofascial trigger points (MTPs).

Materials and Methods

We mapped the nerve fiber distribution into the masseter muscles from 16 cadavers by anatomical dissection. We divided the muscle into six regions, three superior (I–III) and three inferior (IV–VI), and classified the nerve’s branches distribution according to these predetermined areas. Statistical analyses was made by Poisson distribution and logarithm link function followed by Bonferroni multiple comparisons (P<0.05).

Results

All six areas received branches from the masseteric nerve. Areas I and II (upper posterior and upper intermediate, respectively) had a significant higher number of nerve entries as compared to the remaining areas.

Conclusion

The penetration areas of the masseteric nerve have been established and MTPs are found in the innervation zones, clinicians should focus initially on the regions of the penetration points, for diagnostics and therapeutic measures, such as injections, dry needling and soft tissue interventions. Anatomical study of nerve supply to the masseter muscle can provide useful additional knowledge to further understanding masticatory myofascial pain and to direct therapeutic interventions and diagnostic studies of temporomandibular junction dysfunction.

An electroencephalography (EEG) study of short-term electromyography (EMG) biofeedback training in patients with myofascial pain syndrome in the upper trapezius

[Purpose] In the present study, electroencephalography was used to explore neural activity related to electromyography biofeedback training, focusing on pain perception before and after electromyography biofeedback. [Participants and Methods] Twenty-seven participants (female=23; mean age: 28.85 ± 4.99 years) with mild-to-moderate myofascial pain syndrome in the upper trapezius were recruited for this study. All participants underwent electroencephalography recording before, during, and after (0 and 15 min) electromyography biofeedback training. Quantitative electroencephalography analysis was performed to obtain the absolute power of the four main frequency bands. Pain scores before and after electromyography biofeedback were also evaluated by subjective rating. [Results] Electromyography biofeedback increased alpha power and decreased delta power 15 minutes after training, suggestive of relaxation. However, although a tendency for scores to decrease was observed, no significant improvements in pain scores were observed following the intervention. Such results may be due to the short duration of the biofeedback session and the subjective nature of pain assessments. [Conclusion] Despite no obvious changes in pain perception, brief electromyography biofeedback training may induce relaxation in patients with myofascial pain syndrome of the upper trapezius muscle.

Comparison of efficacy of corticosteroid injection versus extracorporeal shock wave therapy on inferior trigger points in the quadratus lumborum muscle: a randomized clinical trial

BACKGROUND

In this study, we aimed to compare the efficacy of corticosteroid trigger point injection (TPI) versus extracorporeal shock wave therapy (ESWT) on inferior trigger points in the quadratus lumborum (QL) muscle.

METHODS

In this single-blind randomized clinical trial, 54 low back pain patients with myofascial trigger points on QL muscle were investigated. Participants were randomly allocated into two groups with A and B pockets. Patients in group A underwent radial ESWT and received 5 treatment sessions (1 per week) and actually were not followed-up. However, patients in group B received corticosteroid TPI and received one session of corticosteroid treatment and followed-up for 4 weeks after injection. Oswestry Disability Index (ODI), visual analogue scale (VAS), pain pressure threshold (PPT) and short form (36) health survey (SF-36) were measured in both groups before, two weeks after and four weeks after intervention.

RESULTS

The between group comparison indicated that corticosteroid TPI leaded to significant higher improvements of ODI (P-value< 0.01), VAS (P value< 0.001), and PPT (P-value = 0.001) scores compared to the ESWT group at two-week follow-up time-point. ESWT group recorded significant higher improvement of ODI (P-value< 0.01) and SF-36 (P-value< 0.001) compared to the corticosteroid TPI at 4th week post treatment evaluation. At four-week follow-up time-point, the patients in the ESWT group were 1.46 times more likely to achieve 30% reduction in VAS, 2.67 times more likely to achieve 30% reduction in ODI, and 2.30 times more likely to achieve 20% improvement in SF-36 compared to the participants in corticosteroid TPI group. These results refer to large effect size for all study outcomes in ESWT group (d = 4.72, d = 1.58, d = 5.48, and d = 7.47 for ODI, PPT, SF-36, and VAS, respectively).

CONCLUSION

Corticosteroid TPI was more effective compared to ESWT in short-term controlling of pain and disability caused by myofascial pain syndrome of QL muscle. However, after 4 weeks treatment, ESWT further improved the quality of life and disability and was related with more probability of achievement the minimal clinically important difference concerning pain, disability and quality of life and large effect size for all study outcomes in treated patients compared to corticosteroid TPI.

TRIAL REGISTRATION

www.irct.ir , IRCT20100827004641N14 , retrospectively registered 2019-01-19.

Day of peak pain reduction by a single session of dry needling in the upper trapezius myofascial trigger points: A 14 daily follow-up study

BACKGROUND

Dry needling (DN) is commonly used to inactivate myofascial trigger points (MTrPs). However, a daily report of pain reduction has not been determined.

OBJECTIVE

The aim was to evaluate the time of the greatest pain relief after performing a single session of DN in MTrPs of the upper trapezius muscle.

METHODS

A patient who had MTrPs in the upper trapezius muscle was enrolled into a prospective descriptive study. Each patient received a single session of DN, using a fast-in-fast-out technique, with needle retention for 30 min. Numerical rating scale (NRS) scores were collected daily for 14 days. The mean difference of pain and an effect size were calculated. The 1-5 satisfaction score was a secondary outcome.

RESULTS

Sixty-seven subjects completed the intervention. The mean duration of the symptom was 27.32 months. The mean baseline NRS score was 5.30. The pain decreased significantly between immediate post-procedure and 1 day after the DN treatment from 5.16 to 3.40 (mean difference 1.76, p < 0.01, effect size = 0.87). The pain continuously reduced until day 10 and then it gradually rose. The pain on day 10 was compared with the baseline that revealed the largest effect size of 3.08 (mean difference 4.67, p < 0.01). Eighty-eight percent of the subjects were very satisfied with their treatment.

CONCLUSIONS

A single session of DN treatment in the upper trapezius MTrPs combined with self-stretching exercises could greatly reduce pain between immediate post-procedure and 1 day after DN treatment. The peak effect on pain reduction occurred on day 10.

Treatment and management of myofascial pain syndrome

Myofascial Pain Syndrome (MPS) is a regional pain disorder that affects every age-group and is characterized by the presence of trigger points (TrPs) within muscles or fascia. MPS is typically diagnosed via physical exam, and the general agreement for diagnostic criteria includes the presence of TrPs, pain upon palpation, a referred pain pattern, and a local twitch response. The prevalence of MPS among patients presenting to medical clinics due to pain ranges anywhere from 30 to 93%. This may be due to the lack of clear criteria and guidelines in diagnosing MPS. Despite the prevalence of MPS, its pathophysiology remains incompletely understood. There are many different ways to manage and treat MPS. Some include exercise, TrP injections, medications, and other alternative therapies. More research is needed to form uniformly-accepted diagnostic criteria and treatments.

Ultrasound Imaging and Rehabilitation of Muscle Disorders: Part 2: Nontraumatic Conditions

Because of its several advantages, ultrasound imaging has started to take place in the diagnostic and therapeutic algorithms of a wide range of musculoskeletal disorders. After the first part on traumatic conditions, in this review, the authors aim to discuss the applicability of ultrasound imaging for nontraumatic muscle disorders in the daily clinical/academic practice. While trying to summarize the whole spectrum (e.g., myofascial pain syndrome, inflammatory diseases, neuromuscular disorders), special emphasis will be given to sarcopenia, which is, by far, the most challenging clinical condition in the era of "aging world." Of note, rehabilitation with regard to the exemplified problems will also be briefed throughout.