Needling therapies in the management of myofascial trigger point pain: a systematic review

Evaluation of the effect of dextrose prolotherapy versus deep dry needling therapy for the treatment of temporomandibular joint anterior disc displacement with reduction: (a randomized controlled trial)

OBJECTIVE

to compare the combined effect of Prolotherapy and Deep Dry Needling (DDN) versus DDN effect on relieving the symptoms of Temporomandibular joint (TMJ) anterior disc displacement.

PATIENTS AND METHODS

The clinical trial randomly allocated forty patients. The (control group) patients received four intraarticular and masseteric DDN sessions, while the (study group) patients were subjected to the exact technique followed by Prolosolution injection. The baseline preoperative measurements included Maximal interincisal opening (MIO), auscultation of the presence of clicking, and Visual Analogue Scale (VAS), which were repeated for postoperative measurements after one, two, five, and eight months.

RESULTS

By the end of the study, all patients expressed apparent improvement in pain MIO and clicking. The inter- and intragroup comparison revealed that the pain score values of the control group after five and eight months were significantly higher than those of the study group. The study group demonstrated more significant MIO calibration than the control group, with insignificant differences between both groups regarding the presence of clicking at any time interval. The associations between clicking and VAS values, between clicking and MIO, and between VAS values and increased MIO were positive in the test group and negative in the control group.

CONCLUSIONS

Dextrose Prolotherapy and DDN were beneficial. However, Prolotherapy demonstrated more significant, sustained, and correlated long-term alleviation of symptoms and increased MIO.

CLINICAL RELEVANCE

The study assesses the sole effect of dextrose prolotherapy on relieving the signs of TMJ anterior disc displacement apart from the impact of the penetrating needle.

CLINICAL TRIAL REGISTRATION

The study was registered on www.

CLINICALTRIALS

gov (#: NCT05821985) by Ahmed Nagi Alghandour.

Myofascial pelvic pain: the forgotten player in chronic pelvic pain

PURPOSE OF REVIEW

In this review article, we discuss myofascial-related chronic pelvic pain, pathophysiology, symptomology, and management options.

RECENT FINDINGS

Despite high prevalence of myofascial pelvic pain, screening is not routinely performed by providers. Treatment modalities include pelvic floor physical therapy, pelvic floor trigger point injections with anesthetics or botulinum toxin A and cryotherapy. Other adjunct modalities, such as muscle relaxants and intravaginal benzodiazepines, are used, but data regarding their effectiveness is sparse.

SUMMARY

Myofascial pelvic pain is an important, though overlooked component of chronic pelvic pain. Multimodal, multidisciplinary approach including patient education, pelvic floor physical therapy, and trigger point injections is the mainstay of the management of myofascial pelvic pain.

Dry Needling in Overhead Athletes with Myofascial Shoulder Pain: A Systematic Review

The treatment of myofascial pain in athletes requires a set of rehabilitation techniques that aim to be effective quickly. In this context, dry needling (DNY) has shown interesting results due to its ability to reduce pain in the short term. Thus, the aim of this study was to investigate the role of DNY in managing myofascial shoulder pain in overhead athletes. PubMed, Scopus and Web of Science were screened up to March 2024, to identify studies that met the following inclusion criteria: overhead athletes with shoulder pain with a DNY approach for myofascial trigger points (MTrPs), RCT, case-control study, feasibility study as the study design. Exclusion criteria were studies that did not include athletes, studies that did not focus on the treatment of MTrPs with DNY, other reviews, no full-text availability and papers written in a language other than English. Out of 399 articles, 165 were excluded as duplicates. Of the 234 articles screened, only 6 articles met the inclusion criteria. A total of 6 studies were included in the systematic review. Initial results showed that DNY improved pain rapidly and in the short term; however, there is still no consensus on the minimum number and the interval between treatments. Major findings reported a rapid potential decrease in perceived pain, shoulder disability and an increase in muscle strength; in this scenario, DNY might be a valid solution in a sports rehabilitation setting.

The role of voltage-gated calcium channel α2δ-1 in the occurrence and development in myofascial orofacial pain

Patients who suffer from myofascial orofacial pain could affect their quality of life deeply. The pathogenesis of pain is still unclear. Our objective was to assess Whether Voltage-gated calcium channel α2δ-1(Cavα2δ-1) is related to myofascial orofacial pain. Rats were divided into the masseter tendon ligation group and the sham group. Compared with the sham group, the mechanical pain threshold of the masseter tendon ligation group was reduced on the 4th, 7th, 10th and 14th day after operation(P < 0.05). On the 14th day after operation, Cavα2δ-1 mRNA expression levels in trigeminal ganglion (TG) and the trigeminal spinal subnucleus caudalis and C1-C2 spinal cervical dorsal horn (Vc/C2) of the masseter tendon ligation group were increased (PTG=0.021, PVc/C2=0.012). Rats were divided into three groups. On the 4th day after ligating the superficial tendon of the left masseter muscle of the rats, 10 ul Cavα2δ-1 antisense oligonucleotide, 10 ul Cavα2δ-1 mismatched oligonucleotides and 10 ul normal saline was separately injected into the left masseter muscle of rats in Cavα2δ-1 antisense oligonucleotide group, Cavα2δ-1 mismatched oligonucleotides group and normal saline control group twice a day for 4 days. The mechanical pain threshold of the Cavα2δ-1 antisense oligonucleotides group was higher than Cavα2δ-1 mismatched oligonucleotides group on the 7th and 10th day after operation (P < 0.01). After PC12 cells were treated with lipopolysaccharide, Cavα2δ-1 mRNA expression level increased (P < 0.001). Cavα2δ-1 may be involved in the occurrence and development in myofascial orofacial pain.

Integrated neuromuscular inhibition technique versus spray and stretch technique in neck pain patients with upper trapezius trigger points: a randomized clinical trial

OBJECTIVE

This study aimed to investigate the difference between the integrated neuromuscular inhibition technique (INIT) and spray and stretch technique in patients with neck pain and upper trapezius active trigger points. Methods: A convenience sample of 60 patients with neck pain and active trigger points were recruited from physiotherapy students and allocated randomly to three groups INIT plus stretching exercise spray and stretch technique plus stretching exercise, and stretching exercise only. Treatment was three times per week for four weeks. Pain intensity by visual analogue scale (VAS), pain pressure threshold (PPT), neck disability by Arabic neck disability index (ANDI), and muscle amplitude in the form of root mean square (RMS) by electromyography (EMG) were measured at baseline and after four weeks. Results: Between groups analysis; the results revealed statistical significant difference between three groups after four weeks of intervention as p =0.0001. Within the group analysis, post hoc tests reported improvement at all variables in both INIT and spray and stretch technique groups with mean differences 64.5 and 65.1 in VAS, 20 and 18.15 in ANDI, -1.45 and -0.81 in PPT, and 2.47 and 1.88 in muscle amplitude, respectively. But there was no statistically significant difference in stretching only group in all variables except VAS.

CONCLUSION

Both INIT and spray and stretch techniques had a clinical and statistical effects on pain, function, PPT, and RMS. According to results, there were statistical significant differences between INIT and spray and stretch groups at post-treatment in all variables except VAS with more favor to INIT group, but there were no clinical differences between INIT and spray and stretch groups.

Efficacy of trigger point dry needling on pain and function of the hip joint: a systematic review of randomized clinical trials

OBJECTIVE

The objective of this study was to assess the evidence for the impact of dry needling (DN) on hip pain and function.

METHODS

Medline/PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL databases were searched systematically through June 2022 for randomized clinical trials (RCTs) investigating the impact of DN on hip pain and function. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess risk of bias. Descriptive analysis was conducted to explain the outcomes and adverse events of DN in hip joint diseases. Meta-analysis was not feasible due to significant heterogeneity.

RESULTS

A total of seven eligible studies (including 273 patients) were included out of 2152 screened records. Five studies were in participants with hip osteoarthritis (OA; n = 3), greater trochanteric pain syndrome (GTPS; n = 1) or piriformis syndrome (n = 1); the other two studies were conducted in healthy athletes (n = 2). Two articles assessed changes in participants' short-term visual analog scale (VAS) scores (<1 week), one of which showed that DN significantly reduced pain (P < 0.05). One-week VAS scores were analyzed in three studies, all of which demonstrated reduced scores following DN (P < 0.05). Hip range of motion (ROM) and muscle force were also improved following DN. No serious side effects were reported.

CONCLUSION

DN may be safe and effective at relieving hip pain and improving hip function. DN performs significantly better than several different types of control intervention (including sham DN, no treatment, corticosteroid injections and laser). Strong evidence (high degree of certainty around the results) is lacking, and future studies should ideally use longer follow-up periods and larger sample sizes.

REVIEW REGISTRATION NUMBER

CRD42022297845 (PROSPERO).

Dry needling, trigger point electroacupuncture and motor point electroacupuncture for the treatment of myofascial pain syndrome involving the trapezius: a randomised clinical trial

OBJECTIVE

The objective of this study was to compare trigger point (TrP) dry needling, TrP electroacupuncture and motor point electroacupuncture of the trapezius muscle for the treatment of myofascial pain syndrome (MPS).

METHODS

This randomised clinical trial included 90 patients divided into three groups. Group 1 was treated with dry needling of TrPs, group 2 with intramuscular electrical stimulation of TrPs, and group 3 with electroacupuncture of motor points and/or the spinal accessory nerve. Each group received seven treatment sessions. The outcomes were the pain score measured by visual analogue scale (VAS) and quality of life evaluated by the 12-item short form (SF-12) health questionnaire. We compared the pain outcome over serial time points using growth curve analysis methods.

RESULTS

Participants in the three groups experienced significant improvements in pain scores over time. The average pain level of participants in group 3 across the repeated assessments was 0.98 units lower than in group 1 (mean difference (95% confidence interval (CI) = 1.74-0.23)), p = 0.012). There were no significant differences in pain scores between participants in groups 1 and 2, and there were no significant differences in quality of life across the three groups at the end of the treatment period.

CONCLUSION

Our results provide evidence that electrical stimulation of motor points and/or of the spinal accessory nerve may be superior in terms of pain relief (but not quality of life) to dry needling and possibly electrical stimulation of trigger points for the management of MPS involving the trapezius.

TRIAL REGISTRATION NUMBER

TRIAL-RBR-43R7RF (Brazilian Clinical Trials Registry).

Improvements after dry needling for craniofacial pain in a patient with chronic rhinosinusitis: a case report

BACKGROUND

Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention.

OBJECTIVE

To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months.

OUTCOMES

After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections.

CONCLUSION

Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessing changes in range of motion in adolescent patients undergoing myoActivation® for chronic pain related to myofascial dysfunction: a feasibility study

Introduction

myoActivation® assessment utilizes systemized movement tests to assess for pain and limitations in motion secondary to myofascial dysfunction. myoActivation needling therapy resolves the myofascial components of pain and is associated with immediately observed changes in pain, flexibility, and range of motion. The principal aim of this feasibility study was to objectively characterize the kinematic metrics of upper and lower body motion before and after myoActivation movement tests and therapy.

Methods

Five consecutive eligible adolescent participants considered appropriate for myoActivation were consented to receive their myoActivation intervention in a motion laboratory. Clinical motion analysis was used to measure the changes in maximum range of motion (maxROM) and maximum angular speed to maximum ROM (speedROM) of movement tests predicted to change. Metrics were analyzed to assess changes over specified time intervals - i) baseline to after initial myoActivation session, and ii) baseline to after complete myoActivation course. Each participant served as their own control.

Results

We demonstrated objective evidence of improved maxROM and/or speedROM in 63% of the movement tests predicted to change after just one session of myoActivation and in 77% of movement tests predicted to change over the complete course of treatment. The myoActivation clinician observed positive change in 11/19 of movement tests across all patients, that were predicted to change after the initial myoActivation session; 81% of these positive changes were confirmed by the kinematic data.

Discussion

Clinical motion analysis provides objective support to clinicians evaluating, treating, and teaching myofascial release. A larger, prospective clinical trial is warranted to explore the impact of myoActivation on movement. Refinement of observation techniques and outcome measures established in this feasibility study will strengthen future clinical motion analysis of the myoActivation process.

Is Dry Needling Treatment an Extra Contribution to Conventional Treatment for Hemiplegic Shoulder Pain? A Prospective, Randomized Controlled Study

Objective

This research was conducted to evaluate the effect of adding dry needling (DN) treatment to conventional rehabilitation for pain, range of motion (ROM), and functionality in patients with hemiplegic shoulder pain (HSP).

Materials and Methods

Patients with HSP (n = 38) were divided into 2 groups. A multimodal rehabilitation protocol, including physical therapy and exercise treatments, was given to both groups (5 sessions per week for 15 sessions). In addition to this rehabilitation, 3 sessions of DN therapy were given to one of the 2 groups. Measurements were a visual analogue scale; ROM; and 2 other scales (Quick Disability of the Arm, Shoulder, Hand; and the Fugl-Meyer Assessment Upper Extremity). Evaluations were made before, after, and at the third month after treatment.

Results

While a statistically significant improvement was seen in both groups in all parameters after their treatments, a statistical superiority was found in the conventional treatment+DN group (P < 0.05). However, the differences were not greater than the minimal clinically important difference values (MCID). At the 3rd month follow-up, there was no difference in pain and functionality parameters between the groups, while flexion and abduction measurements were higher in the conventional treatment+DN group (P < 0.05).

Conclusions

Adding DN treatment to conventional rehabilitation did not show any difference except in some joint ROM measurements in the subacute time. Although the changes found were statistically significant, they were not clinically significant as they did not reach MCID values.This study was registered prospectively at ClinicalTrials.gov (ref. no: NCT04790071).

Effectiveness of Dry Needling and Ischaemic Trigger Point Compression of the Levator Scapulae in Patients with Chronic Neck Pain: A Short-Term Randomized Clinical Trial

BACKGROUND

Chronic neck pain (CNP) may be associated with latent myofascial trigger points (MTrPs) in the levator scapulae (LS), which can be treated with ischemic compression (IC) and dry needling (DN). Variables and elastography changes are evaluated to compare the short-term efficacy of two treatments with DN.

METHODS

A randomized clinical trial is conducted with 80 participants in two groups: the DN group (n = 40) and IC group (n = 40). The duration is 12 weeks, and mechanical heterogeneity index, pressure pain threshold (PPT), and pain intensity are measured at baseline, immediately after, 48 h after, and one week after treatment.

RESULTS

Statistically significant changes were immediately observed between the two groups: PPT decreased in the DN group (p = 0.05), while it increased in the IC group. At 48 h and one week after treatment, these values increased in the DN group and remained higher than in the IC group. The heterogeneity index improved in both groups but more significantly in the DN group than in the IC group.

CONCLUSIONS

In subjects with CNP who had latent plus hyperalgesic MTrPs in the LS muscle, DN outperformed IC in PPT, pain intensity, and mechanical heterogeneity index at 48 h and one week after initiating therapy.

Effect of Dry Needling on the Masseter Muscle in the Tinnitus Perception of Patients with Temporomandibular Disorder

Objective

To evaluate the effect of dry needling on the masseter muscle in the perception of tinnitus in patients with temporomandibular disorder.

Methods

Twenty-five patients with tinnitus and muscular temporomandibular disorders were randomly assigned to groups study (n = 13) and control (n = 12). Three sessions of dry needling (study) and sham (control) were performed. Follow-up was performed 30, 60 and 90 days after the end of treatment. The Analog Visual Scale and Tinnitus Handicap Inventory (THI) were used to evaluate the treatment.

Results

In study group, 76.9% presented a reduction in the intensity and tinnitus discomfort and total THI. In control group, 66.7% presented a decrease in tinnitus intensity and total THI, and 58.3% reported a decrease in tinnitus discomfort. After 90 days, in the study group, 84.6% maintained improvement in pain intensity and reduction in THI score and 69.2% reported improvement in both intensity and discomfort caused by tinnitus. In control group, 75% achieved improvement in pain intensity, 33.2% maintained improvement in tinnitus intensity, and 41.7% maintained improvement in discomfort caused by tinnitus and total THI. In the total THI score, the study group presented improvement (p = 0.041).

Conclusion

Dry needling combined with counseling was associated with improvement in pain intensity and tinnitus, decrease in tinnitus discomfort and reduction in total THI score.

Trigger Point Injections Versus Medical Management for Acute Myofascial Pain: A Systematic Review and Meta-Analysis

Myofascial pain is a common problem resulting in musculoskeletal pain characterized by myofascial trigger points. These trigger points can cause substantial discomfort and functional limitations. This meta-analysis aims to assess the effectiveness and safety of trigger point injections versus medical management alone in treating acute onset myofascial pain. A thorough search was conducted across four databases, namely, PubMed, SCOPUS, Web of Science (WOS), and Cochrane Library, to identify randomized controlled trials that compared the effectiveness of trigger point injections versus medical management for the treatment of acute myofascial pain. The search encompassed articles published from the databases' inception until June 2023. The relevant data were extracted and analyzed using the standardized mean difference (SMD) and 95% confidence interval (CI). Of the 1151 records identified, four met the inclusion criteria for the systematic review, and all were included in the meta-analysis. The analysis of four randomized controlled trials (RCTs) showed that trigger point injections were effective in reducing pain scores compared to medical treatment (SMD = -2.09 (95% CI: -3.34 to -0.85, P = 0.001)). The data revealed a negative standardized mean difference, which was significant and consistent in favor of trigger point injections. Overall, these findings highlight the beneficial impact of trigger point injections in reducing acute myofascial pain when compared to isolated medical management.

Clinical Effectiveness of Dry Needling in Patients with Musculoskeletal Pain-An Umbrella Review

The number of systematic reviews (SR) summarizing the literature regarding the clinical effects of Dry Needling (DN) has increased rapidly. Yet, rigorous evidence about the clinical effectiveness of this technique is still lacking. The aim of this umbrella review is to summarize the evidence about the clinical effects of trigger point DN on musculoskeletal disorders across all body regions. PubMed, Web of Science and Embase were searched to identify SRs examining the effect of DN (as a stand-alone intervention or combined with another treatment modality) compared to sham/no intervention or a physical therapy (PT) intervention with at least one clinical outcome in the domain of pain or physical functioning. Risk of bias (RoB) was assessed with the AMSTAR-2 tool. Quantification of the overlap in primary studies was calculated using the corrected covered area (CCA). The electronic search yielded 2286 results, of which 36 SRs were included in this review. Overall, DN is superior to sham/no intervention and equally effective to other interventions for pain reduction at short-term regardless of the body region. Some SRs favored wet needling (WN) over DN for short-term pain reductions. Results on physical functioning outcomes were contradictory across body regions. Limited data is available for mid- and long-term effects. DN has a short-term analgesic effect in all body regions and may be of additional value to the interventions that are used to date in clinical practice. Several studies have shown an additional treatment effect when combining DN to physiotherapeutic interventions compared to these interventions in isolation. There is a substantial need for the standardization of DN protocols to address the problem of heterogeneity and to strengthen the current evidence.

Suggesting a mechanism for acupuncture as a global percutaneous needle fasciotomy that respects tensegrity principles for treating fibromyalgia

Acupuncture is a minimally invasive therapeutic method that uses small caliber needles while inserting them through the skin into various areas of the body. Some empirical studies find evidence to support the use of acupuncture as a treatment for certain medical conditions, however, this peculiar practice is widely considered as the domain of alternative and non-evidence-based medicine. Several mechanisms have been suggested in an attempt to explain the therapeutic action of acupuncture, but the way in which acupuncture alleviates chronic non-cancer pain or psychosomatic and psychiatric disorders is not fully understood. A recent study suggested a theoretical model (coined "Fascial Armoring") with a cellular pathway to help explain the pathogenesis of myofascial pain/fibromyalgia syndrome and functional psychosomatic syndromes. It proposes that these syndromes are a spectrum of a single medical entity that involves myofibroblasts with contractile activity in fascia and aberrant extracellular matrix (ECM) remodeling, which may lead to widespread mechanical tension and compression. This can help explain diverse psycho-somatic manifestations of fibromyalgia-like syndromes. Fascia is a continuous interconnected tissue network that extends throughout the body and has qualities of bio-tensegrity. Previous studies show that a mechanical action by needling induces soft tissue changes and lowers the shear modulus and stiffness in myofascial tissue. This hypothesis and theory paper offers a new mechanism for acupuncture therapy as a global percutaneous needle fasciotomy that respects tensegrity principles (tensegrity-based needling), in light of the theoretical model of "Fascial Armoring." The translation of this model to other medical conditions carries potential to advance therapies. These days opioid overuse and over-prescription are ubiquitous, as well as chronic pain and suffering.

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.

Broaden Horizons: The Advancement of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating disease that induces mental stress, lower urinary symptoms, and pelvic pain, therefore resulting in a decline in quality of life. The present diagnoses and treatments still lead to unsatisfactory outcomes, and novel diagnostic and therapeutic modalities are needed. Although our understanding of the etiology and pathophysiology of IC/BPS is growing, the altered permeability of the impaired urothelium, the sensitized nerves on the bladder wall, and the chronic or intermittent sensory pain with inaccurate location, as well as pathologic angiogenesis, fibrosis, and Hunner lesions, all act as barriers to better diagnoses and treatments. This study aimed to summarize the comprehensive information on IC/BPS research, thereby promoting the progress of IC/BPS in the aspects of diagnosis, treatment, and prognosis. According to diverse international guidelines, the etiology of IC/BPS is associated with multiple factors, while the presence of Hunner lesions could largely distinguish the pathology, diagnosis, and treatment of non-Hunner lesions in IC/BPS patients. On the basis of the diagnosis of exclusion, the diverse present diagnostic and therapeutic procedures are undergoing a transition from a single approach to multimodal strategies targeting different potential phenotypes recommended by different guidelines. Investigations into the mechanisms involved in urinary symptoms, pain sensation, and bladder fibrosis indicate the pathophysiology of IC/BPS for further potential strategies, both in diagnosis and treatment. An overview of IC/BPS in terms of epidemiology, etiology, pathology, diagnosis, treatment, and fundamental research is provided with the latest evidence. On the basis of shared decision-making, a multimodal strategy of diagnosis and treatment targeting potential phenotypes for individual patients with IC/BPS would be of great benefit for the entire process of management. The complexity and emerging evidence on IC/BPS elicit more relevant studies and research and could optimize the management of IC/BPS patients.

Effectiveness of Dry Needling and Ischemic Trigger Point Compression in the Gluteus Medius in Patients with Non-Specific Low Back Pain: A Randomized Short-Term Clinical Trial

BACKGROUND

The presence of latent myofascial trigger points (MTrPs) in the gluteus medius is one of the possible causes of non-specific low back pain. Dry needling (DN) and ischemic compression (IC) techniques may be useful for the treatment of these MTrPs.

METHODS

For this study, 80 participants were randomly divided into two groups: the dry needling group, who received a single session of DN to the gluteus medius muscle plus hyperalgesia (n = 40), and the IC group, who received a single session of IC to the gluteus medius muscle plus hyperalgesia (n = 40). Pain intensity, the pressure pain threshold (PPT), range of motion (ROM), and quality of life were assessed at baseline, immediately after treatment, after 48 h, and one week after treatment.

RESULTS

Statistically significant differences were shown between the two groups immediately after the intervention, showing a decrease in PPT (p < 0.05) in the DN group and an increase in PPT in the IC group. These values increased more and were better maintained at 48 h and after one week of treatment in the DN group than in the IC group. Quality of life improved in both groups, with greater improvement in the DN group than in the IC group.

CONCLUSIONS

IC could be more advisable than DN with respect to UDP and pain intensity in the most hyperalgesic latent MTrPs of the gluteus medius muscle in subjects with non-specific low back pain, immediately after treatment. DN may be more effective than IC in terms of PPT, pain intensity, and quality of life in treating latent plus hyperalgesic gluteus medius muscle MTrPs in subjects with non-specific low back pain after 48 h and after one week of treatment.

A Pilot Analysis on the Efficacy of Multiple Trigger-Point Saline Injections in Chronic Tension-Type Headache: A Retrospective Observational Study

This study aimed to investigate the efficacy of new targeted trigger-point injections (TPIs) using isotonic saline in patients with chronic tension-type headache (CTTH). Of 121 patients with headache who were retrospectively reviewed, 19 were included in this study and were categorized into two groups: those who received TPIs more than four times (group 1); and those who received TPIs less than, or equal to, four times (group 2). The patients received ultrasound-guided isotonic saline injections into the active trigger points once weekly. The primary outcome was an effect on headache intensity, determined using the visual analog scale (VAS), whereas the secondary outcome was an effect on quality of life, evaluated using the Henry Ford Hospital Headache Disability Inventory (HDI). The mean symptom duration of the 19 patients (11 men and 8 women; mean age, 52.5 years; and range, 23−81 years) was 16 months. The most frequently injected muscle was the splenius capitis. Patient demographics were similar between the two groups (p > 0.05). Simple linear regression revealed that symptom duration (p = 0.001) and baseline VAS score (p = 0.009) were significantly associated with the number of injections. At one month after the first injection, the mean VAS and HDI scores in group 2 were significantly lower than those in group 1 (p < 0.05), whereas the scores significantly decreased immediately after the last injection in both groups (p < 0.05). No adverse effects were reported in any patient. Our results indicate that the administration of new targeted TPIs using isotonic saline into the head and neck muscles of patients with CTTH can effectively relieve headache intensity and safely improve their quality of life.

Complementary Effect of Electro Acupuncture on Refractory Head and Neck Myofascial Pain: A Retrospective Investigation of Patient-Reported Outcomes

Introduction:

Acupuncture (AC) is among the complementary treatment modalities to manage chronic myofascial pain. The aim of this investigation was to assess the additive effect of AC in reducing the intensity of primary chronic myalgia/myofascial head and neck pain in patients using oral orthotic appliances (OA).

Methods:

A retrospective chart review was conducted for 103 patients diagnosed with primary chronic myalgia/myofascial pain and received OA with/without AC at Tufts University School of Dental Medicine (TUSDM). Subjective reporting of face/TMJ/neck pain was recorded at the initial visit and at short-term and long-term follow-ups using patient-reported pain/discomfort numeric rating scale (NRS).

Results:

Most subjects were females (77.7%) with the mean age of the entire study population being 53 years old. In patients with refractory response to OA, combining AC with OA showed significant improvement in NRS score compared to baseline, in TMJ pain (P=0.023), neck pain (P= 0.055), facial pain (P=0.006). The addition of AC to OA has also brought refractory pain to low levels, comparable to what OA-only respondents reported [TMJ pain (P= 0.395), neck pain (P=0.694), face pain (P=0.553)].

Conclusion:

AC may provide a complementary therapeutic modality to manage refractory cases of primary chronic myofascial pain.

Efficacy of Dry Needling Under EMG Guidance for Myofascial Neck and Shoulder Pain: A Randomized Clinical Trial

Purpose

To determine the difference in maintenance of improvement of pain and disability for dry needling (DN) under needle electromyography (EMG) guidance technique in myofascial neck and shoulder pain patients, compared with DN alone.

Patients and Methods

In this randomized single-blind clinical trial, 30 participants with myofascial pain in the neck and shoulder were randomly allocated to two groups: myofascial trigger points (MTrPs) DN with EMG guided (DN-EMG) group and MTrPs DN without EMG (DN) group. Needling treatment lasted for 2 weeks, twice a week. The primary outcome was pain intensity as assessed by visual analogue scale (VAS) and neck disability index (NDI). A number of mappings referred to pain and spontaneous muscle activity (SEA) were considered secondary outcomes. VAS and NDI were measured before treatment, after 2 weeks of intervention and at 4-, 6- and 12-week follow-up periods after the intervention. Secondary outcomes were assessed before each treatment (T1-T4). Data were analysed using mixed-model analyses of variance (ANOVA) with time as a within-subject variable and groups as between-subject variables followed by Bonferroni's post-hoc test.

Results

Mixed-model ANOVA revealed significant time-by-group interaction effects (F = 3.49, P = 0.01) for VAS. Post-hoc analysis showed a significant decrease in VAS and NDI after 2 weeks of intervention and at all follow-up periods compared with baseline in both groups (p < 0.01). The DN-EMG group exhibited higher improvements in VAS at 6- and 12-week follow-up period than the DN group (p < 0.05). In the SEA of MTrPs, we found positive sharp waves, fibrillation and fascicular potentials. DN-EMG group exhibited lower amplitudes at T2-T4 and frequencies at T2 and T3.

Conclusion

DN under needle EMG guidance technique exhibited greater improvements in maintenance of improvement of pain and lower SEA value than the DN group due to sufficient MTrPs inactivation.

Trigger Point Injections

Myofascial pain and myofascial pain syndromes are among some of the most common acute and chronic pain conditions. Many interventional procedures can be performed in both an acute and chronic pain setting to address myofascial pain syndromes. Trigger point injections can be performed with or without imaging guidance such as fluoroscopy and ultrasound; however, the use of imaging in years past has been recommended to improve patient outcome and safety. Injections can be performed using no injectate (dry needling), or can involve the administration of local anesthetics, botulinum toxin, or corticosteroids.

Quantitative Ultrasound Texture Feature Changes With Conservative Treatment of the Trapezius Muscle in Female Patients With Myofascial Pain Syndrome

OBJECTIVE

We set out to assess whether quantitative ultrasound could be used to assess changes that occur after physical therapy in patients experiencing myofascial pain syndrome.

METHODS

We consecutively recruited female subjects experiencing myofascial pain syndrome of the neck and shoulder region and provided 10 sessions of conservative physical therapy. A control group was recruited for textural analyses. We measured change in pain ratings, range of motion, and ultrasound texture features before and after the intervention and after 3 mos.

RESULTS

We recruited 63 female myofascial pain syndrome subjects and 20 healthy controls. After treatment, the mean blob size (an ultrasound texture feature) value for each subject decreased from 30.84 ± 5.00 to 25.86 ± 5.67 on the right and decreased from 31.70 ± 5.51 to 28.08 ± 5.53 on the left (P < 0.0005). The blob count showed a significant increase only on the left side (P < 0.01). Corresponding to this were reductions in pain and disability scores after treatment and at 3 mos compared with retreatment (P < 0.0005 for all checkpoints). Cervical range of motion values were significantly increased only at 3 mos compared with pretreatment except for mean flexion range of motion.

CONCLUSIONS

Ultrasound texture feature of blob size and count changes correspond to routine clinical outcomes after conservative physical therapy of myofascial pain syndrome in female individuals.

Masticatory Myofascial Pain Syndrome: Implications for Endodontists

INTRODUCTION

Masticatory myofascial pain syndrome can present similarly to other dental conditions in odontogenetic structures. Endodontists should be familiar with the symptomology and pathophysiology of masticatory myofascial pain syndrome to avoid misdiagnosis, incorrect treatment, and medicolegal repercussions. The aim of this review was to provide a foundational summary for endodontists to identify and correctly manage masticatory myofascial pain syndrome.

METHODS

A narrative review of the literature was performed through a MEDLINE search and a hand search of the major myofascial pain textbooks.

RESULTS

Masticatory myofascial pain syndrome is a musculoligamentous syndrome that can present similarly to odontogenic pain or refer pain to the eyebrows, ears, temporomandibular joints, maxillary sinus, tongue, and hard palate. Currently, the most comprehensive pathophysiology theory describing masticatory myofascial pain syndrome is the expanded integrated hypothesis. The most widely accepted diagnostic guidelines for masticatory myofascial pain syndrome are the Diagnostic Criteria for Temporomandibular Disorders; however, their diagnostic capability is limited. There is no hierarchy of treatment methods because each patient requires a tailored and multidisciplinary management aimed at regaining the muscle's range of motion, deactivating the myofascial trigger points, and maintaining pain relief.

CONCLUSIONS

The pain patterns for masticatory myofascial pain syndrome are well-known; however, there is a lack of consensus on the most proper method of trigger point diagnosis or pain quantification. The diagnostic strategies for masticatory myofascial pain syndrome vary, and the diagnostic aids are not well developed.

Myofascial pain syndrome and SARS-CoV-2: a case series

SARS-CoV-2 is a novel virus that has caused a plethora of dysfunctions and changes in the human body. Our goal in this case study series was to demonstrate the relationship that coronavirus has had in newly diagnosing patients with myofascial pain syndrome (MFPS). Medical records were obtained from a pain clinic that demonstrated the effects of this virus on patients who developed MFPS between March 2020 and December 2020. Chart reviews were performed and demonstrated patients who had a history of chronic pain had subsequent episodes of worsening exacerbations of pain, more specifically trigger points, after being diagnosed with coronavirus. MFPS and SARS-CoV-2 are proposed to be correlated amongst chronic pain patients. Potential pathological mechanisms include coronavirus-induced hypoxic muscle dysfunctions as well as psychological stress triggering pain receptors, leading to myofascial pain syndrome.

COVID-19, the disease caused by the SARS-CoV-2 virus, may cause many problems and changes in the human body. In this case series, we propose a relationship between COVID-19 and myofascial pain syndrome (MFPS), a kind of chronic muscle pain affecting connective tissue in the muscles. Medical records of people who developed MFPS after a diagnosis of COVID-19 between March 2020 and December 2020 were obtained from a pain clinic. Chart reviews demonstrated that the three people with chronic pain included in this case series had episodes of worsening pain, more specifically in focal points, after being diagnosed with COVID-19. COVID-19 is suggested to have affected the development of MFPS in these chronic pain patients. Potential mechanisms of this relationship include different types of stress leading to MFPS.

Comparison of dry needling and kinesio taping methods in the treatment of myofascial pain syndrome: A single blinded randomised controlled study

OBJECTIVES

The aim of this study was to compare the effectiveness of kinesio taping (KT) and dry needling (DN) in the treatment of myofascial pain syndrome (MPS) of the trapezius muscle.

METHODS

The patients with MPS were divided into 3 groups as those who received exercise only (control group), those who received KT and exercise (KT group) and those who received DN and exercise (DN group) by using a sealed opaque envelope randomisation method. Visual Analog Scale (VAS), Pressure Pain Threshold (PPT), Neck Disability Index (NDI) and Global Perceived Effect Scale (GPES) were measured twice at baseline and at the end of the second week by blinded evaluator.

RESULTS

A total of 26 patients were assigned to KT group, 32 to DN group and 30 to control group. The results of the study showed that PPT, VAS and NDI scores were significantly improved in the KT (1.61 ± 1.25, -2.66 ± 1.24 and -7.08 ± 6.24, respectively) and DN (1.30 ± 1.13, -3.34 ± 1.40 and -10.63 ± 7.80 respectively) groups (P < .001 for all). In the control group, no significant improvement was found in the VAS (.10 ± 1.39) and NDI (-.83 ± 4.91) scores (P > .05), with a significant decrease in PPT (-.98 ± 1.92) (P = .014). KT and DN methods in MPS treatment have more positive effects in terms of pain, disability and global effect compared to the control group.

CONCLUSIONS

In the treatment of MPS, adding DN or KT to exercise programme may provide important contributions to the treatment.

Effects of Botulinum Toxin Type A on Pain among Trigeminal Neuralgia, Myofascial Temporomandibular Disorders, and Oromandibular Dystonia

The differences in analgesic effects of botulinum toxin type A were compared in 28 patients with trigeminal neuralgia, 53 patients with myofascial temporomandibular disorders, and 89 patients with the jaw closing oromandibular dystonia. The patients were treated by injection of botulinum toxin type A into the masseter, temporalis, medial pterygoid, and other muscles based on the symptoms of each patient. The pain severity was evaluated using the visual analog scale, pain frequency, and pain scale of the oromandibular dystonia rating scale. Botulinum toxin injection was performed 1068 times in all patients without significant adverse effects. The visual analog, pain frequency, and pain scales at baseline were reduced (p < 0.001) after two, four, eight, and 12 weeks after the first botulinum toxin therapy and at the endpoint. The effects differed significantly (p < 0.001) among the groups (repeated-measures analysis of variance). The mean improvement (0%, no effect; 100%, complete recovery) at the endpoint was 86.8% for trigeminal neuralgia, 80.8% for myofascial pain, and 75.4% for oromandibular dystonia. Injection of the botulinum toxin can be a highly effective and safe method to treat trigeminal neuralgia, myofascial pain, and oromandibular dystonia.

Dry needling has lasting analgesic effect in shoulder pain: a double-blind, sham-controlled trial

Supplemental Digital Content is Available in the Text.

Dry needling has analgesic effects in shoulder pain associated with myofascial pain syndrome. The analgesic effects last for up to 1 week.

Introduction:

Myofascial pain syndrome (MPS) affects most patients with chronic shoulder pain. Dry needling (DN) is a common treatment for MPS, but its temporal pattern and sensory effects remain unknown.

Objectives:

We evaluated in a randomized, sham-controlled study the pattern of analgesic efficacy and local sensory changes of a single session of DN for MPS in patients with chronic shoulder pain.

Methods:

Patients with chronic shoulder pain were randomized into active (n = 20) or sham (n = 21) groups. A single DN was performed by a researcher blinded to group assignment and pain outcomes. Pain intensity was assessed by the numeric rating score, and sensory thresholds were evaluated with a quantitative sensory testing protocol, including the area of tactile sensory abnormalities 7 days before needling, right before, and 7 days after the intervention.

Results:

Dry needling led to significant larger pain intensity reduction (from 6.30 ± 2.05 to 2.40 ± 2.45 in the active group; P = 0.02, effect size = −1.3 (95% CI [−2.0 to −0.68]); (number necessary to treat = 2.1). Pain reduction scores were significantly different on the second day after needling and persisted so until the seventh day and were accompanied by improvement in other dimensions of pain and a decrease in the area of mechanical hyperalgesia in the active DN group alone (P < 0.05).

Conclusion:

Active trigger points DN provided analgesic effects compared with sham and decreased the area of local mechanical hyperalgesia. These findings have practical clinical implications and may provide mechanistic insights behind MPS.

Trigger point injections for axial back pain in adolescents

Adolescents who participate in athletics or have abnormal musculoskeletal anatomy have higher incidences of back pain than non-athletic peers with normal anatomy. Significant time and money spent in diagnostic evaluations for axial back pain can result in treatment delay causing a subsequent decrease in quality of life. Myofascial trigger points are a commonly overlooked reason for axial back pain. They develop due to an abnormal myoneural connection in the setting of muscle overuse. Trigger point injections are a technically simple intervention that is both diagnostic and therapeutic in alleviating trigger point-mediated back pain. There are few complications from these injections, and they should be considered prior to surgical referral or fluoroscopic-guided interventions.

An unusual complication of quadriparesis after trigger point injection: a case report

ABSTRACT

Quadriparesis after intramuscular trigger point injections for myofascial pain syndrome has been rarely reported in the literature. A 37-year-old male patient presented with myofascial pain syndrome and was given trigger point injections in trapezius muscles under ultrasound guidance. The patient noticed weakness in all the 4 limbs at approximately 12 hours after the procedure, which gradually progressed to functional quadriplegia at the time of presentation to the emergency department. On examination, he had quadriparesis with no sensory involvement and superficial reflexes were normal. MRI screening of the whole spine was unremarkable, and MRI brain suggested an incidental granuloma, which could not explain his symptoms. Blood tests revealed severe hypokalemia (2.2 mEq/L) and deranged thyroid function tests. Immediate potassium correction with intravenous and oral potassium chloride was initiated, and the patient showed improvement within 6 hours of initiating correction. Stress of the procedure, use of steroids with mineralocorticoid effects such as methylprednisolone, or deranged thyroid function tests may have acted as triggers to precipitate hypokalemic paralysis in the patient. Knowledge of this complication is essential as prompt diagnosis and timely management of hypokalemia can result in complete resolution of the symptoms.

Dry needling trigger points around knee and hip joints improves function in patients with mild to moderate knee osteoarthritis

INTRODUCTION

Dry needling may be an effective method to alleviate pain and improve range of motion. Controversial results have been found in previous studies using dry needling in knee problems. So, the aim of current study is to exert dry needling technique on unilateral muscles around the hip and knee joints and evaluate its effects on knee osteoarthritic patients.

METHOD

For this double-blind randomized clinical trial, 40 female patients with mild to moderate knee osteoarthritis (aged 45-70 years old) were recruited. They entered the study if they had any trigger points around the hip or knee joints of the examined side and randomized into two groups. Pain, sensitivity of trigger points, balance and function measured by visual analogue scale, algometer, Y-balance test, timed up and go, self-paced walk tests beside KOOS questionnaire respectively before and after intervention. The intervention group received 3 sessions of dry needling on marked trigger points while the sham group received sham treatment consisting of only the plastic cover of a needle. Both groups reexamined 2 weeks after primary evaluation.

RESULTS

Comparing results before and after implementing dry needling revealed significant improvements in all measured variables in treatment group whereas, pain and timed up and go increased and peak pain pressure decreased in sham group. Between group comparison revealed significant differences in all variables.

CONCLUSION

Using 3 sessions of dry needling can increase functional activity, sensitivity and balance and decrease pain in patients with knee osteoarthritis in short term.

Effect of magnesium sulfate iontophoresis on myofascial trigger points in the upper fibres of the trapezius

Objective

To investigate the immediate and post-treatment effect of magnesium sulfate (MgSO4) iontophoresis on myofascial trigger points (MTrPs) in the upper fibres of the trapezius muscle.

Method

Sixty participants (41 women and 19 men, aged 19–24 years) with active MTrPs on the dominant upper fibres of trapezius were enrolled in this study. They were randomly divided into 2 equivalent groups: the intervention and the control group. The intervention group (iontophoresis group; n = 30) was treated with MgSO4 iontophoresis on the upper fibres of the trapezius twice a week for four weeks, and the control group (direct current group; n = 30) received direct current (without medication) in the upper fibres of the trapezius twice a week for four weeks. The outcome measures were: pain intensity, pain threshold, neck range of motion, and neck function The participants were assessed before treatment, immediately after the first session, and finally after treatment.

Results

The differences within and between groups were measured using a mixed design, multivariate analysis of variance (MANOVA). The within- and between-group analysis of all outcome measures in both groups revealed significant differences in favour of the intervention group (p < 0.05).

Conclusion

MgSO4 iontophoresis is effective in improving pain level, neck ROM, and neck function immediately after the first session and causes more significant improvement after treatment in subjects with active MTrPs on the dominant upper fiber of trapezius.

Noble metal sensitized invasive porous bioelectrodes: advanced medical device for enhanced neuronal activity and chronic alcohol treatment

Invasive bioelectrodes are widely used as an effective treatment for several acute and chronic diseases. In earlier work using high surface area invasive porous bioelectrodes evaluated in an animal model of alcoholism withdrawal, we demonstrated significantly improved electrophysiological and behavioral responses. In this study, we further modify the surface of these invasive porous bioelectrodes with noble metal (Ag, Au, Pt) nanoparticles. Compared to both conventional and porous bioelectrodes, noble metal sensitized invasive porous bioelectrodes show markedly increased low threshold (LT) and wide dynamic range (WDR) neuronal activity. In particular, Pt-sensitized invasive porous bioelectrodes show the highest WDR neuronal activity only upon insertion. In addition, Ag-sensitized invasive porous bioelectrodes, whose surface area is about 37 times greater than that of conventional bioelectrodes, show improved electrochemical properties with higher LT and WDR neuronal activity when stimulated. In an animal model of chronic alcoholism, using normal and alcohol-treated Sprague-Dawley (SD) rats evaluated with the elevated plus maze (EPM) test, the Ag-sensitized invasive porous bioelectrodes show about 20% higher open arms time. These results suggest that these noble metal-sensitized invasive bioelectrodes may offer improved therapeutic outcomes for the treatment of chronic alcoholism, and given these enhanced electrophysiological properties, for other conditions as well.

Myofascial Pain Syndrome and Its Relation to Trigger Points, Facial Form, Muscular Hypertrophy, Deflection, Joint Loading, Body Mass Index, Age and Educational Status

Introduction:

Myofascial pain (MFP) is a type of pain characterized by the presence of a trigger point (TrPs) in taut band of skeletal muscles or its fascia. Based on the current literature, the prevalence of head and neck myofascial pain (HNMFP) varies among different communities. To better understand this condition and its relation to facial form, muscular hypertrophy, deflection, and joint loading, the study aimed at evaluating the prevalence of HNMFP among the population of Jeddah, Saudi Arabia.

Materials and Methods:

This was a cross-sectional study to survey a sample of Jeddah residents, Saudi Arabi between the ages of 18–65 for HNMFP who were attending a public event in December 2019. Participants were asked to complete a questionnaire for demographics and history of HMFP signs and symptoms followed by a comprehensive clinical examination including facial form, muscular hypertrophy, maximum vertical opening, and joint loading. In addition, examination of upper quarter muscles was completed using flat or pincer palpation as needed. Data were collected and summarized as frequencies and percentages and group differences were tested using the chi-square statistical method.

Results:

A total of 197 participants were examined in this study, in which 136 (69.0%) had signs and symptoms consistent with HNMFP. Study subjects’ educational status was significantly associated with HNMFP (P = 0.008). Older subjects were more likely to report spontaneous pain whereas younger subjects were more likely to report pain following trauma (P = 0.049). Older subjects were more likely to have muscular hypertrophy (P = 0.011), while Younger subjects were more likely to have symmetrical facial form (P = 0.004). In terms of gender, males were more likely to experience pain aggravation with pressure and cold application whereas females were more sensitive to jaw function (P = 0.015). Distribution of joint loading showed a statistically significant difference between males and females (P = 0.008) with females having deflection on opening more frequently compared to males (P = 0.001). Furthermore, female subjects showed a significantly higher frequency of positive TrPs compared to males.

Conclusion:

Based on the current data, HNMFP is a common condition among the population of Jeddah. Factors such as body mass index and educational level were found to be linked to HNMFP. Younger subjects were more likely to have symmetrical facial form while older subjects were more likely to have muscular hypertrophy. The distribution of joint loading showed a statistically significant difference between males and females with females having deflection on opening more frequently compared to males. Further studies with a larger group of patients are needed to confirm these findings.

Comparison between dry needling plus manual therapy with manual therapy alone on pain and function in overhead athletes with scapular dyskinesia: A randomized clinical trial

Muscles' trigger points can induce scapular dyskinesia (SD) which interferes with overhead athletes' professional training. We aimed to evaluate effects of dry needling (DN) alone and plus manual therapy (MT) on pain and function of overhead athletes with SD. 40 overhead athletes (15 male, 25 female) aged 18-45 with at least 3 points Numeric Rating Scale (NRS) pain intensity during training were recruited and randomly allocated to the treatment group: MT followed by DN on trigger points of Subscapularis, Pectoralis minor, Serratus anterior, upper and lower Trapezius muscles; or the control group: MT alone. The effect of shoulder trigger points DN plus MT with MT alone on pain, function, Pain Pressure Threshold (PPT) and SD in athletes with SD were compared. Both the examiner and the therapist were blinded to group assignment. Both groups were analyzed. Pain, disability and SD were improved in treatment group (P < .05). On the other hand, when only MT was applied, despite reduction in pain and disability (P < .001), scapular slide only improved in hands on waist position. Comparing the differences between groups showed a substantial reduction in pain (P < .001) and disability (P = .02) with significant improvement in scapular dyskinesia in treatment group (P = .02). Moreover, PPT significantly increased in the control group (P = .004). No adverse effects reported by the participants during this study. DN is an easy and applicable method that can synergistically reduce pain, disability and dyskinesia when it is combined with manual techniques to treat shoulder dysfunctions.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

Ultrasound-guided dextrose injection treatment for chronic myofascial pain syndrome: A retrospective case series

BACKGROUND

Due to the lack of an evidence-based consensus, managing refractory myofascial pain syndrome is challenging for clinicians. Dextrose injection (dextrose prolotherapy) emerged as a promising, cost-effective treatment. This study evaluated the efficacy of targeted ultrasound-guided dextrose injection for localized myofascial pain syndrome.

METHODS

We retrospectively reviewed the clinical outcomes of 45 patients with myofascial pain syndrome refractory to alternative treatments with targeted ultrasound-guided dextrose injection. Pretreatment symptom severity and symptomatic response 1 month after treatment were statistically analyzed using a visual analog scale (VAS)-based scoring system.

RESULTS

Of 45 patients, 8 (24.4%) reported complete resolution of symptoms at the treated site. In total, 36 (80.0%) patients reported greater than 50% improvement in their symptoms. The mean pretreatment and posttreatment VAS scores were 7.0 and 2.44 (p < 0.001), indicating an overall 65.0% reduction in symptom severity.

CONCLUSION

Targeted ultrasound-guided dextrose injection was remarkably effective for refractory localized myofascial pain syndrome, significantly reducing symptom intensities in the majority of treated patients within 1 month after a single injection.

Pain Management During the COVID-19 Pandemic

Chronic pain management during the coronavirus disease 2019 (COVID-19) pandemic is a challenging process, especially with growing evidence that COVID-19 infection is associated with myalgias, referred pain, and widespread hyperalgesia. In light of the limited data available for COVID-19-related impact on chronic pain patients, this review explores the changes in the healthcare delivery system due to social distancing and safety precautions to provide the appropriate management of chronic pain patients during the COVID-19 pandemic. Understanding both the general problems facing chronic pain patients as well as specific problems in the COVID-19 era including deconditioning, increased mental health concerns, financial burdens, and potential for medication-induced immune-suppression is vital in the appropriate management of patients. Telemedicine, the practice of caring for patients remotely when the provider and patient are not physically present with each other, is becoming increasingly used and recognized as a valuable tool to both health care providers and patients. This paper concentrates on the proper utilization of the available resources to help patients with the most severe conditions as well as the most vulnerable group. COVID-19 may be associated with a profound effect on both the health care system and patients with chronic pain. As a result, delaying, or stopping, treatment for chronic pain patients will have negative consequences, and strong pain evaluations must be administered to triage patients appropriately. Recent recommendations for the safe use of non-opioid analgesics, opioid analgesics, and interventional pain management procedures are vital to know and understand specifically during the pandemic era. Further researches are needed to identify the advance planning and rapid responses to reduce the impact of the pandemic.

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.

Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises

BACKGROUND

It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for.

METHODS

To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period.

RESULTS

In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization.

CONCLUSIONS

The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.

Botulinum toxin injection for chronic pelvic pain: A systematic review

INTRODUCTION

Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain.

MATERIAL AND METHODS

Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies.

RESULTS

In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However, only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported.

CONCLUSIONS

Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Effects of Dry Needling Technique Into Trigger Points of the Sternocleidomastoid Muscle in Migraine Headache: A Randomized Controlled Trial

OBJECTIVE

The study aimed to investigate the effect of dry needling into trigger points of the sternocleidomastoid muscle in migraine headache patients.

DESIGN

Forty subjects with a migraine headache, originating from myofacial trigger points into the sternocleidomastoid muscle (20 subjects in dry needling group and 20 subjects in control group) volunteered to participate in this study. The subjects in the treatment group received three sessions of dry needling in the myofascial trigger point region. Headache frequency, headache intensity, headache duration, drug consumption, muscle thickness, pressure pain threshold, and cervical range of motion were assessed before, immediately after intervention, and at 1-mo follow-up period. In addition, this article was extracted from Iranian Register of Clinical Trials Number IRCT20171219037956N1.

RESULTS

The experimental group showed significant reduction in the headache parameters immediately after the intervention and at 1-mo follow-up, as compared with the control group. The pressure pain threshold of sternocleidomastoid muscle, cervical range of motion, and muscle thickness significantly increased in the dry needling group in comparison with the control group (P < 0.001).

CONCLUSIONS

The application of dry needling technique caused an improvement in symptoms of migraine patients. Therefore, this technique may be prescribed for treating migraine patients with myofacial trigger points in the sternocleidomastoid muscle.

The Effect of Dry Needling on Lower Limb Dysfunction in Poststroke Survivors

BACKGROUND

Spasticity is one of the main complications in poststroke survivors leading to difficulties in walking and standing resulting in high levels of disability.

OBJECTIVE

The aim of the study was to investigate the effects of deep dry needling on lower limb dysfunction in poststroke spastic patients.

METHODS

A randomized clinical trial conducted in poststroke survivors who were assigned to one of 2 groups: Deep dry needling (intervention group) and sham dry needling (control group). The primary outcome measures were Modified Modified Ashworth Scale (MMAS) and functional tests (timed up and go test, 10-meter walk test). Secondary outcome measures were active ankle dorsiflexion range of motion (AROM), passive ankle dorsiflexion range of motion (PROM), single leg stance test, and Barthel index. All measurements were assessed at baseline (T0), immediately after the third session 1 week later (T1), and 1 month after the end of the intervention (T2).

RESULTS

We recruited 24 patients (71% male; mean age 57 ± 10 years; 26.4 ± 1.8 kg•m^-2; time since event: 25.2 ± 12.5 months). There were significant improvements in MMAS, timed up and go test, 10-meter walk test, Barthel scale, and PROM (P < .05) in the intervention group compared to controls across the time-points. There were no significant improvements in AROM assessments (P > .05).

CONCLUSIONS

Deep dry needling decreases muscle spasticity and improves lower limb function and gait speed in poststroke survivors.

The effectiveness of acupuncture in the management of persistent regional myofascial head and neck pain: A systematic review and meta-analysis

Persistent head and neck myofascial pain is among the most frequently reported pain complaints featuring major variability in treatment approaches and perception of improvement. Acupuncture is one of the least invasive complimentary modalities that can optimize conventional treatment. The aim of this review was to determine the evidence for the effectiveness of acupuncture in the management of localized persistent myofascial head and neck pain. Only randomized controlled clinical trials (RCTs) were included. The search was conducted in PubMed, Ovid Medline, Embase, Google Scholar, and Cochrane Library in addition to manual search. The main outcome measure was the comparison of the mean pain intensity score on VAS between acupuncture and sham-needling/no intervention groups. Safety data and adherence rate were also investigated. Six RCTs were identified with variable risk of bias. All included studies reported reduction in VAS pain intensity scores in the groups receiving acupuncture when compared to sham needling/no intervention. Meta-analysis, using a weighted mean difference as the effect estimate, included only 4 RCTs, revealed a 19.04 point difference in pain intensity between acupuncture and sham-needling/no intervention (95 %CI: -29.13 to -8.95). High levels of safety were demonstrated by the low rates of side effects/withdrawal. Inconsistency in reporting of outcomes was a major limitation. In conclusion, moderate-quality evidence suggests that acupuncture may be an effective and safe method in relieving persistent head and neck myofascial pain. Optimizing study designs and standardizing outcome measures are needed for future RCTs.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.