Validity and Reliability of Clinical Examination in the Diagnosis of Myofascial Pain Syndrome and Myofascial Trigger Points in Upper Quarter Muscles

Dry needling in people with fibromyalgia: A randomized controlled trial of its effects on pain sensitivity and pain catastrophizing influence

BACKGROUND

Dry needling (DN) has been demonstrated as an effective treatment for patients with fibromyalgia (FM). It is crucial to take into consideration catastrophizing, a psychological construct that could potentially undermine the short-term efficacy of DN.

OBJECTIVE

To analyze the effects of DN in the infraspinatus muscle on both local and remote pressure pain thresholds (PPTs) and its relationship with baseline levels of pain catastrophizing in patients with FM.

DESIGN

Randomized controlled trial.

METHODS

All participants were randomly assigned to one of three interventions: DN, sham DN, and no intervention. Hong's fast-in and fast-out technique was implemented during the DN intervention.

MAIN OUTCOMES MEASURES

The primary study outcome pain sensitivity (local and remote PPTs) was assessed at baseline, immediately post, and 24 h post intervention to evaluate short-term effect. Pain catastrophizing was measured at baseline in all participants using the Pain Catastrophizing Scale. To analyze the effect of DN on local and remote PPTs, an analysis of covariance was performed using catastrophism as covariate. Additionally, to examine the possible influence of catastrophism on local PPTs ratings in the subsequent assessment we performed a moderation analysis.

PATIENTS

A total of 120 women diagnosed with FM. However, during the follow-up period, 24 participants discontinued their involvement, leaving a final cohort of 96 patients who successfully concluded the study.

RESULTS

DN showed significant differences in both local PPTs immediately post intervention and 24 h post intervention (MD [95% confidence interval] = 3.21 [0.40-6.02] kg/cm2, p = .019; and 2.84 [0.10-5.58] kg/cm2, p = .039, respectively) compared to sham and no-intervention groups. In addition, DN group results suggest that moderate values of catastrophizing (<35) diminish the effect of DN immediately postintervention.

CONCLUSIONS

The infraspinatus DN led to a notable reduction in local PPTs among individuals with FM. Additionally, the effectiveness of the DN treatment was influenced by pain catastrophizing.

Use of One-minute Sit-to-stand Test to Predict Functional Exercise Capacity in Patients With Congenital Heart Disease

INTRODUCTION

Field tests are commonly used as complements of cardiopulmonary exercise test (CPET) to evaluate the functional exercise capacity. The aims of this study were to validate the one-minute sit-to-stand test (STST) in congenital heart disease (CHD) children and to evaluate the possibility of predicting the peakVO2 using the STST in this paediatric population.

METHODS

Children (8- to 18-year-old) followed for a CHD and performing CPET were recruited prospectively. Concomitantly, they performed STST. The heart rate (HR), oxygen saturation (SpO2), muscular fatigue and dyspnoea were recorded before (t0), immediately after (t1) and 1min after the end of the STST (t2).

RESULTS

We observed a poor but significant correlation between the STST and the peakVO2 (r=0.306; p=0.013). A significant difference between girls and boys were observed for peakVO2 (p<0.001), HR t0 (p=0.030), HR t1 (p=0.002) and HR t2 (p<0.001). The proposed model of prediction, including the number of STST, weight, height and age explains 37% of the predicted peakVO2 variance.

CONCLUSION

The STST can provide relevant data on physical capacity in children with CHD. When CPET cannot be performed, we therefore propose an alternative equation using the STST as a surrogate of peakVO2 in CHD children.

Profiling migraine patients according to clinical and psychophysical characteristics: clinical validity of distinct migraine clusters

AIMS

Investigate if different clinical and psychophysical bedside tools can differentiate between district migraine phenotypes in ictal/perictal (cohort 1) and interictal (cohort 2) phases.

METHOD

This observational study included two independent samples in which patients were subgrouped into distinct clusters using standardized bedside assessment tools (headache frequency, disability, cervical active range of motion, pressure pain threshold in different areas): (A) cohort 1-ictal/perictal migraine patients were subgrouped, based on previous studies, into two clusters, i.e., Cluster-1.1 No Psychophysical Impairments (NPI) and Cluster-1.2 Increased Pain Sensitivity and Cervical Musculoskeletal Dysfunction (IPS-CMD); (B) cohort 2-interictal migraine patients were subgrouped into three clusters, i.e., Cluster-2.1 NPI, Cluster-2.2 IPS, and Cluster-2.3 IPS-CMD. Clinical characteristics (multiple questionnaires), somatosensory function (comprehensive quantitative sensory testing (QST)), and cervical musculoskeletal impairments (cervical musculoskeletal assessment) were assessed and compared across headache clusters and a group of 56 healthy controls matched for sex and age.

RESULTS

Cohort 1: A total of 156 subjects were included. Cluster-1.2 (IPS-CMD) had higher headache intensity (p = 0.048), worse headache-related (p = 0.003) and neck-related disability (p = 0.005), worse quality of life (p = 0.003), and higher symptoms related to sensitization (p = 0.001) and psychological burden (p = 0.005) vs. Cluster-1.1(NPI). Furthermore, Cluster-1.2 (IPS-CMD) had (1) reduced cervical active and passive range of motion (p < 0.023), reduced functionality of deep cervical flexors (p < 0.001), and reduced values in all QST(p < 0.001) vs. controls, and (2) reduced active mobility in flexion, left/right lateral flexion (p < 0.045), and reduced values in QST (p < 0.001) vs. Cluster-1.1 (NPI). Cohort 2: A total of 154 subjects were included. Cluster-2.3 (IPS-CMD) had (1) longer disease duration (p = 0.006), higher headache frequency (p = 0.006), disability (p < 0.001), and psychological burden (p = 0.027) vs. Cluster-2.2 (IPS) and (2) higher headache-related disability (p = 0.010), neck-related disability (p = 0.009), and higher symptoms of sensitization (p = 0.018) vs. Cluster-2.1 (NPI). Cluster-2.3(IPS-CMD) had reduced cervical active and passive range of motion (p < 0.034), and reduced functionality of deep cervical flexors (p < 0.001), vs. controls, Custer-2.1 (NPI), and Cluster-2.2 (IPS). Cluster-2.2 (IPS) and 2.3 (IPS-CMD) had reduced QST values vs. controls (p < 0.001) and Cluster-2.1 (p < 0.039).

CONCLUSION

A battery of patient-related outcome measures (PROMs) and quantitative bedside tools can separate migraine clusters with different clinical characteristics, somatosensory functions, and cervical musculoskeletal impairments. This confirms the existence of distinct migraine phenotypes and emphasizes the importance of migraine phases of which the characteristics are assessed. This may have implications for responders and non-responders to anti-migraine medications.

Test-retest reliability of the isometric contraction test (IC test) of the masticatory muscles in subjects with and without temporomandibular muscle disorders

OBJECTIVE

Recently, the DC/TMD has become an essential tool for the diagnosis of temporomandibular disorders (TMD). However, as they fail to include functional activities, new assessment proposals have emerged, such as the isometric contraction test (IC test) of the masticatory muscles, which uses muscle contractions to identify muscular TMD. This study aimed to determine the test-retest reliability of the IC test.

METHODS

A total of 64 participants (40 women and 24 men) completed the IC test administered by two different physical therapists on two non-consecutive days. Cohen's kappa (k), PABAK, and percent agreement (PA) between days were estimated.

RESULTS

The IC test showed good to excellent test-retest reliability values (k>0.77; PABAK>0.90), both globally and individually for the muscles evaluated, and PA>90%, therefore above the thresholds for clinical applicability. However, the global assessment of myofascial pain and the evaluation of the medial pterygoid muscle showed slightly lower reliability values.

CONCLUSION

The IC test is reliable for the assessment of subjects with muscular TMD, both in terms of the global assessment and the evaluation of each muscle, which supports its clinical applicability. Care should be taken when assessing myofascial pain globally and when evaluating the medial pterygoid in all types of pain.

A model for personalized diagnostics for non-specific low back pain: the role of the myofascial unit

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Cervical musculoskeletal impairments and pain sensitivity in migraine patients

INTRODUCTION

Currently, examination of migraine patients relies on a clinical interview investigating symptoms characteristics. Despite this, to help identify distinct migraine subtypes and allow a personalized treatment approach, biomarkers to profile distinct migraine subtypes should be utilized in clinical and research settings. Therefore, there is a need to include physical and psychophysical examinations aimed at assessing migraine features quantitatively.

PURPOSE

This paper aimed to discuss if increased pressure pain sensitivity and impaired cervical musculoskeletal function could be considered 1) as quantitative features of migraine and 2) if they could be used as biomarkers to profile migraine patients in distinct subtypes.

IMPLICATION

Increased pain sensitivity and cervical musculoskeletal impairments have been suggested as quantitative biomarkers to phenotype and subgroup migraine patients in clinical and research settings. This could provide the first step for a mechanistically-driven and personalized treatment approach according to migraine phenotypes.

Migraine patients with and without neck pain: Differences in clinical characteristics, sensitization, musculoskeletal impairments, and psychological burden

AIMS

This study aims to assess differences in clinical characteristics across healthy controls and migraine patients with (MNP) and without (MwoNP) neck pain.

METHOD

This study assessed: headache frequency; headache disability index (HDI); central sensitization inventory (CSI); Hospital Anxiety (HADS-A) and Depression (HADS-D) scale; active range of motion (AROM); flexion rotation test (FRT); activation pressure score (APS); number of active/latent myofascial trigger points (MTrPs) in head/neck muscles; number of positive cervical vertebral segments (C1/C2) who reproduce migraine pain; wind-up ratio (WUR); mechanical pain threshold (MPT) and static pressure pain threshold (sPPT) over the trigeminal area; sPPT and dynamic PPT (dPPT) over the cervical area; sPPTs and MPT over the hand.

RESULTS

Compared to controls, MNP had: worse CSI, HADS-A, and HADS-D (all, p < 0.002); reduced AROM (flexion, extension, left lateral-flexion, and right-rotation), FRT, APS, and a higher number of MTrPs and positive cervical vertebral segments (all, p < 0.020); reduced trigeminal MPT and sPPT, cervical sPPT and dPPT, hand MPT and sPPT (all, p < 0.006). Compared to controls, MwoNP had: worse CSI, and HADS-A (all, p < 0.002); reduced AROM (flexion, and left lateral-flexion), FRT, APS, and a higher number of MTrPs and positive cervical vertebral segments (all, p < 0.017); reduced trigeminal MPT and cervical dPPT (all, p < 0.007). Compared to MwoNP, MNP had higher headache frequency, worse HDI and CSI (all, p < 0.006); reduced AROM (flexion, and right rotation) (all, p < 0.037); reduced cervical dPPT (all, p < 0.002).

CONCLUSION

MNP had worse headache characteristics, more pronounced cervical musculoskeletal impairments, enhanced signs and symptoms related to sensitization, and worse psychological burden compared to MwoNP.

Evidence for an association of serum microanalytes and myofascial pain syndrome

BACKGROUND

Myofascial Pain Syndrome (MPS) is a common pain disorder. Diagnostic criteria include physical findings which are often unreliable or not universally accepted. A precise biosignature may improve diagnosis and treatment effectiveness. The purpose of this study was to assess whether microanalytic assays significantly correlate with characteristic clinical findings in people with MPS.

METHODS

This descriptive, prospective study included 38 participants (25 women) with greater than 3 months of myofascial pain in the upper trapezius. Assessments were performed at a university laboratory. The main outcome measures were the Beighton Index, shoulder range of motion, strength asymmetries and microanalytes: DHEA, Kynurenine, VEGF, interleukins (IL-1b, IL-2, IL-4, IL-5, IL-7, IL-8, IL-13), growth factors (IGF-1, IGF2, G-CSF, GM-CSF), MCP-1, MIP-1b, BDNF, Dopamine, Noradrenaline, NPY, and Acetylcholine. Mann-Whitney test and Spearman's multivariate correlation were applied for all variables. The Spearman's analysis results were used to generate a standard correlation matrix and heat map matrix.

RESULTS

Mean age of participants was 32 years (20-61). Eight (21%) had widespread pain (Widespread Pain Index ≥ 7). Thirteen (34%) had MPS for 1-3 years, 14 (37%) 3-10 years, and 11 (29%) for > 10 years. The following showed strong correlations: IL1b,2,4,5,7,8; GM-CSF and IL 2,4,5,7; between DHEA and BDNF and between BDNF and Kynurenine, NPY and acetylcholine. The heat map analysis demonstrated strong correlations between the Beighton Index and IL 5,7, GM-CSF, DHEA. Asymmetries of shoulder and cervical spine motion and strength associated with select microanalytes.

CONCLUSION

Cytokine levels significantly correlate with selected clinical assessments. This indirectly suggests possible biological relevance for understanding MPS. Correlations among some cytokine clusters; and DHEA, BDNF kynurenine, NPY, and acetylcholine may act together in MPS. These findings should be further investigated for confirmation that link these microanalytes with select clinical findings in people with MPS.

Buccal acupuncture combined with ultrasound-guided dry needle-evoked inactivation of trigger points to treat cervical and shoulder girdle myofascial pain syndrome

BACKGROUND

Myofascial pain syndrome (MPS) is a common disease with easy persistence and recurrence. In clinical practice, although many methods have been adopted to prevent and treat MPS, the control of MPS is still not satisfactory.

OBJECTIVE

To compare the safety and effectiveness of buccal acupuncture, inactivation of trigger points (MTrPs), and their combination in the treatment of MPS.

METHODS

Two hundred MPS patients in the pain clinic were randomly divided into four groups (n= 50) to receive oral drugs (Group A), oral drugs + buccal needle (Group B), oral drugs + MTrP inactivation (Group C), or oral drugs + buccal needle + MTrP inactivation (Group D).

RESULTS

The visual analogue scale (VAS) and cervical range of motion (ROM) of Group D were significantly lower than those of the other three groups, and the pressure pain threshold (PPT) value of labelled MTrPs was significantly higher than those of the other three groups (P< 0.05). The excellent rate and total effective rate of Group D were significantly higher than those of the other three groups. Group C had the highest pain score and the lowest acceptance score. The results showed that buccal acupuncture combined with ultrasound-guided dry needle-evoked inactivation of MTrPs can significantly reduce the VAS score of MPS patients, improve the range of motion of the cervical spine, and improve patient satisfaction.

CONCLUSIONS

This study provides a highly accepted and satisfactory treatment for MPS, which is worthy of clinical promotion.

Validity of the Isometric Contraction Test of the Masticatory Muscles for Diagnosis of Muscular Temporomandibular Disorders

In recent years, the Diagnostic Criteria for Temporomandibular Pain Disorders (DC/TMD) has been questioned, mainly because of the dependence on the muscular pressure needed to be applied during the clinical examination. Therefore, it is necessary to establish improvements in diagnostic strategies for DC/TMD of axis I. The aim of this study was to determine the validity of the Isometric Contraction Test of the masticatory muscles (ICTest) to diagnose DC/TMD of axis I. Forty (n = 40) patients with muscular TMD (myalgia in any of its subtypes), as well as forty age and sex matched controls, participated. They were diagnosed according to DC/TMD of axis I and performed the ICTest in a single session. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and positive (LR+) and negative likelihood ratios (LR−) of the ICTest compared with the DC/TMD of axis I were calculated. The ICTest showed a specificity of 95% for the diagnosis of myalgia, and between 94.9% and 96.8% for all subtypes in relation to the DC/TMD of axis I. For sensitivity, lower values were obtained, that is, 90.0% for myalgia, and losing sensitivity depending on the type of myalgia. The LR+ was over 10 for all diagnoses, with the exception of myofascial pain with referral, which was lower. When addressing the LR−, the myofascial diagnosis was the only one below 0.2. According to the results, the ICTest could be considered a valid procedure to diagnose subjects with muscular TMD in a clinical setting.

Diagnostic Applications of Ultrasonography in Myofascial Trigger Points: A Scoping Review and Critical Appraisal of Literature

Objective:

Myofascial trigger points (MTrPs) are pathognomonic of myofascial pain syndrome. The detection ability of MTrPs via ultrasonography is underreported and the characteristics of MTrPs are not sufficiently standardized. The objective was to summarize the characteristics and diagnostic abilities of ultrasonography for MTrP investigations.

Materials and Methods:

A multi-database, and bibliography hand-search was implemented. Studies of ≥10 patients, published after 1980, appraising ultrasonography as a diagnostic aid for myofascial pain syndrome were included. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to evaluate the diagnostic accuracy of the included studies.

Results:

Six cross-sectional studies met the inclusion criteria. The back and trapezius muscles were the most studied locations. The diagnostic studies were of low-medium risk of bias. The studies reported a large range of diagnostic metrics (accuracy 58%–100%, sensitivity 33%–91%, specificity 75%–100%, positive predictive value 91%–100%, negative predictive value 47%–97%, positive likelihood ratio 3.6, and negative likelihood ratio 0.12–0.67).

Conclusion:

This review found low-medium risk of bias evidence in support of ultrasonography for MTrP investigations. The clinical studies identified in the scoping review used gray-scale ultrasound equipment systems with a 5 to 14 MHz transducer to diagnose MTrPs and the local twitch response, and MTrPs were visualized mostly as hypoechoic nodules.

Cervical musculoskeletal impairments in the 4 phases of the migraine cycle in episodic migraine patients

OBJECTIVE

To assess cervical musculoskeletal impairments during the 4 phases of a migraine cycle in episodic migraine patients, controlling for the presence of concomitant neck pain.

METHODS

Differences in cervical musculoskeletal impairments were assessed during the 4 migraine phases in episodic migraine patients and compared with healthy controls controlling for concomitant neck pain. Cervical musculoskeletal impairments were assessed as follow: cervical active range of motion; flexion rotation test; craniocervical flexion test and calculation of activation pressure score; the total number of myofascial trigger points in head/neck muscles; the number of positivevertebral segments (headache's reproduction) during passive accessory intervertebral movement; pressure pain thresholds over C1, C2, C4, C6 vertebral segments bilaterally, trigeminal area, hand, and leg. Signs of pain sensitization were assessed by evaluating mechanical pain threshold over trigeminal area and hand, pressure pain thresholds, and the wind-up ratio. The Bonferroni-corrected p-value (05/4 = 0.013) was adopted to assess the difference between groups, while a p-value of 0.05 was considered significant for the correlation analysis.

RESULTS

A total of 159 patients and 52 controls were included. Flexion rotation test and craniocervical flexion test were reduced in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). The number of myofascial trigger points and positive vertebral segments was increased in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). Flexion, extension, and total cervical active range of motion and cervical pressure pain thresholds were reduced in episodic migraine in the ictal phase versus controls (p < 0.007) with no other significant differences. Outside the ictal phase, the total cervical active range of motion was positively correlated with trigeminal and leg pressure pain threshold (p < 0.026), the number of active myofascial trigger points and positive positive vertebral segments were positively correlated with higher headache frequency (p=0.045), longer headache duration (p < 0.008), and with headache-related disability (p = 0.031). Cervical pressure pain thresholds were positively correlated with trigeminal, hand, and leg pressure pain threshold (p < 0.001), and trigeminal and leg mechanical pain thresholds (p < 0.005), and negatively correlated with the wind-up ratio (p < 0.004).

CONCLUSION

In all phases of the migraine cycle, independent of the presence of concomitant neck pain, episodic migraine patients showed reduced flexion rotation test and craniocervical flexion test and an increased number of myofascial trigger points and passive accessory vertebral segments. These impairments are correlated with enhanced headache duration, headache-related disability, and signs of widespread pain sensitization. Reduction in active cervical movement and increased mechanical hyperalgesia of the cervical was consistent in ictal episodic migraine patients and the subgroups of episodic migraine patients with more pronounced widespread sensitization.

Cost-Effectiveness of Upper Extremity Dry Needling in Chronic Stroke

Introduction: Dry needling is a non-pharmacological approach that has proven to be effective in different neurological conditions. Objective: The aim of this study was to evaluate the cost-effectiveness of a single dry needling session in patients with chronic stroke. Methods: A cost-effectiveness analysis was performed based on a randomized controlled clinical trial. The results obtained from the values of the EuroQol-5D questionnaire and the Modified Modified Ashworth Scale were processed in order to obtain the percentage of treatment responders and the quality-adjusted life years (QALYs) for each alternative. The cost analysis was that of the hospital, clinic, or health center, including the equipment and physiotherapist. The cost per respondent and the incremental cost-effectiveness ratio of each alternative were assessed. Results: Twenty-three patients with stroke were selected. The cost of DN treatment was EUR 14.96, and the data analysis showed a favorable cost-effectiveness ratio of both EUR/QALY and EUR/responder for IG, although the sensitivity analysis using limit values did not confirm the dominance (higher effectiveness with less cost) of the dry needling over the sham dry needling. Conclusions: Dry needling is an affordable alternative with good results in the cost-effectiveness analysis—both immediately, and after two weeks of treatment—compared to sham dry needling in persons with chronic stroke.

EFFECT OF MANUAL THERAPY INTERVENTIONS ON RANGE OF MOTION AMONG INDIVIDUALS WITH MYOFASCIAL TRIGGER POINTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

OBJECTIVE

Patients with myofascial trigger points (MTPs) frequently manifest restricted range of motion (ROM) during physical evaluation. Multiple manual therapy interventions have been developed for the treatment of MTPs, but their effect on ROM has not been clarified through a systematic review and meta-analysis. Thus, this systematic review aimed to assess the effect of manual therapy interventions on ROM among individuals with MTPs.

METHODS

A systematic search was conducted in PubMed, Web of Science, Cochrane, Scopus and Clinical Trials.gov. Articles analysing the effect of manual therapy interventions on ROM were included. The risk of bias was assessed using the Cochrane RoB2 tool. The DerSimonian-Laird method was used to compute the pooled effect size (ES) and its 95% confidence interval (95% CI) for ROM.

RESULTS

A total of 13 randomized controlled trials (RCTs) were included in this systematic review and meta-analysis. The pooled ES for ROM was 0.52 (95% CI: 0.42; 0.63). The pooled ES for ROM evaluated in centimetres was 0.36 (95% CI: 0.14; 0.59) and the pooled ES for ROM evaluated in degrees was 0.57 (95% CI: 0.47; 0.68).

CONCLUSION

Manual therapy interventions may be an effective approach for improving ROM among individuals with MTPs.

Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review

OBJECTIVE

The objective of this study was to conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.

METHODS

MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points," "trigger point," "myofascial trigger point," "myofascial trigger points," "myofascial pain," and "myofascial pain syndrome." The MeSH keywords were combined by using Boolean operators "OR"/"AND." All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least 1 active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.

RESULTS

Of 478 possibly relevant publications, 198 met the inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the 6 criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness," "referred pain," and "local twitch response" (n=28 studies, 22%).

CONCLUSIONS

A number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain, and local twitch response were the 3 most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.

Effects of an active intervention based on myofascial release and neurodynamics in patients with chronic neck pain: a randomized controlled trial

BACKGROUND

While neck pain can be severely disabling and costly, treatment options have shown moderate evidence of effectiveness.

OBJECTIVE

The objective of this study was to explore the effects of a 4-week active program based on myofascial release and neurodynamics on trigger point (TrP) examination, pain, and functionality in patients with chronic neck pain.

METHODS

Randomized controlled trial. A total of 40 patients with chronic neck pain were randomly allocated to an experimental or a control group (n = 20). The primary outcome measure was TrP examination. Secondary outcomes were pain, assessed with the Brief Pain Inventory and a visual analogue scale, and functionality, evaluated with the Neck Outcome Score.

RESULTS

A between-group analysis showed significant differences (p < .05) in the percentage of active TrPs in the following muscles: suboccipital (50 vs. 92.4% in the right muscle and 37.5 vs. 89.6% in the left muscle), left scalene and levator scapulae. Significant differences (p < .05) were also found in pain severity, average pain, and functionality (i.e. symptoms, sleep, and participation).

CONCLUSIONS

A 4-week self-administered program for patients with chronic neck pain was effective in reducing the presence of active TrPs. Pain severity, average pain, and some aspects of functionality also improved significantly after the intervention.

[Myofascial chronic pelvic pain in women : A retrospective evaluation of the effects of specific diagnostics and therapy]

BACKGROUND

The prevalence of chronic pelvic pain of 11.8% in the general population underlines the importance of this disease. However, the specific diagnostics and therapy of the muscles of this region are not yet part of the standard examination. The following study examines the effects of specific diagnostics and therapy on myofascial chronic pelvic pain.

OBJECTIVES

The effectiveness of targeted diagnostics and multimodal therapy in the context of chronic pelvic pain and the need for a complementary drug adjustment.

MATERIALS AND METHODS

This study retrospectively evaluated the data of 59 patients, who were referred to a pain center for treatment-resistant chronic pelvic pain in the period from January 2012 to April 2017. The pain needed to be clearly identified as myofascial. A previous minimum duration of pain as well as previous operations or other treatment procedures did not constitute exclusion criteria. Previous traumatization was a reason for exclusion. Therapy components included manual therapeutic treatment, training in self-stretching exercises, medication with the active ingredients flupirtine or methocarbamol, as well as relaxation procedures. Therapy was evaluated on the basis of the German Pain Questionnaire.

RESULTS

After the treatment interval, the following statistically significant improvements were recorded: The average pain intensity decreased by 29.95 points (standard deviation [SD] = 20.61). General quality of life (Marburg questionnaire on habitual well-being, MFHW) increased by 1.1 points (SD = 0.73). The depression and anxiety assessment decreased by 2.56 (SD = 3.99) and 2.63 points (SD = 5.21) respectively.

CONCLUSION

A multimodal therapy concept with a manual therapeutic treatment focus can lead to an improvement in pain symptoms and quality of life in patients with myofascial chronic pelvic pain after a treatment period of 120 days. Myofascial syndromes of urogenital muscles must be considered in the assessment of the cause of chronic pelvic pain.

Myofascial pain syndrome and trigger points: evaluation and treatment in patients with musculoskeletal pain

PURPOSE OF REVIEW

Myofascial pain syndrome is a chronic pain condition characterized by the presence of myofascial trigger point, a hyperirritable painful spot involving a limited number of muscle fibers. The literature suggest that myofascial trigger points should be considered peripheral pain generators and this critical review will summarize recent findings concerning the clinical evaluation and the treatment of myofascial trigger points.

RECENT FINDINGS

The clinical features of myofascial trigger points and their contribution to the patient pain and disability have been detailed in several recent studies, which support the clinical relevance of the condition. Recent studies reported that manual palpation to identify MTrPs has good reliability, although some limitations are intrinsic to the diagnostic criteria. During the last decade, a plethora of treatments have been proposed and positive effects on pain and function demonstrated.

SUMMARY

The myofascial trigger point phenomenon has good face validity and is clinically relevant. Clinicians are encouraged to consider the contribution of myofascial trigger points to the patient's pain and disability through a careful medical history and a specific manual examination. Patients with myofascial trigger points will benefit from a multimodal treatment plan including dry needling and manual therapy techniques. Internal and external validity of research within the field must be improved.

The Interexaminer Reproducibility and Prevalence of Lumbar and Gluteal Myofascial Trigger Points in Patients With Radiating Low Back Pain

Objective

To determine the interexaminer reproducibility for judging the presence, number, and location of leg-pain referring myofascial trigger points, and their prevalence in patients with low back pain with and without concomitant leg pain referral.

Design

An interexaminer reproducibility study.

Setting

An outpatient public Hospital Spine Centre in Southern Denmark.

Participants

Examiners: experienced examiners (N=2), a chiropractor and a physiotherapist, respectively. Subjects: a case mix of patients with low back pain (N=32) with and without leg pain referral.

Interventions

A standardized palpation examination protocol of 4 bilateral lumbosacral muscles performed by each examiner.

Main Outcome Measures

Reproducibility on presence (measured in Cohen’s κ), number (difference and limits of agreement), location (distance between matching marks placed by examiners), and prevalence of myofascial trigger points.

Results

Kappa values of the examined muscles were as follows: quadratus lumborum (κ=0.42), gluteus medius (κ=0.83), gluteus minimus (κ=0.74), and piriformis (κ=0.62), with a mean of all examined muscles of kappa=0.66, assessed as substantial agreement. The mean difference in number of trigger points was 0.8, with limits of agreement ranging from −6.4 to 4.9. Mean distance between trigger point locations was 12.9 mm, with 57% only being identified by a single examiner. The prevalence of trigger points was 82.7%, highest in the gluteal region of the painful side.

Conclusions

Inadequate standardization and multiple trigger point sites complicate interexaminer reproducibility on location and number of patients with low back pain and leg pain referral. Nevertheless, substantial interexaminer reproducibility for the trigger point presence appears achievable. Implemented routinely, this relatively simple clinical evaluation procedure could meaningfully enhance diagnostic triage and eventual management.

Myofascial pain and treatment: Editorial

The first article featured in this quarter's overview deserves special attention. Margalef and colleagues developed the first viable animal model of trigger points (TrPs). They also provided evidence of glycosaminoglycans (GAGs) near TrPs, which is a new finding that deserves further scientific inquiry (Margalef et al 2019). In 2011, Stecco et al. already mentioned a possible role of hyaluronan, which constitutes a subgroup of GAGs, in the etiology of myofascial pain (Stecco et al 2011). Mayoral Del Moral and colleagues published an excellent study that showed very good inter-examiner reliability for identifying subjects with MPS for identifying specific muscles (Mayoral Del Moral et al 2018). Sollmann and colleagues described a new and objective method to identify TrPs, using T2 mapping with quantitative MRI-based techniques (Sollmann et al 2016). As usual, many new dry needling (DN) studies, reviews, manual TrP papers and case reports are included. Finally, we would like to thank Dr. Michelle Finnegan for her contributions to this overview paper during the past 5 years. Dr. Finnegan will be focusing on other professional endeavors and she will not return as a contributing author.

A critical overview of the current myofascial pain literature - February 2019

This edition of the overview of current myofascial pain literature features several interesting and important publications. From Australia, Braithwaite and colleagues completed an outstanding systematic review of blinding procedures used in dry needling (DN) studies. Other papers tackled the interrater reliability of the identification of trigger points (TrP), the presence of muscle hardness related to latent TrPs, pelvic floor examination techniques, and the links between TrPs, headaches and shoulder pain. Israeli researchers developed a theoretical model challenging the contributions of the Cinderella Hypothesis to the development of TrPs. As in almost all issues, we included many DN, injection and acupuncture studies, which continue to be the focus of researchers all over the world.

A critical overview of the current myofascial pain literature - November 2018

This is the first issue of this review column since the passing of Dr. Leon Chaitow. We would like to take a brief moment to acknowledge how much his mentorship, friendship, and confidence have meant to us. Leon was a force in osteopathic and naturopathic medicine and his influence reaches to all corners of the musculoskeletal realm crossing over many disciplines through his lectures, workshops, and of course, his many books, editorials, and articles. In the foreword to one of his books, Jan Dommerholt wrote that "Leon Chaitow […] continued the work of Travell and Simons, but also of many others, whose contributions he has skillfully woven into an intricate tapestry of clinical pearls, practical tips, and solid evidence-informed research." Dr. Chaitow was a synthesizer, who always considered what different clinicians and researchers could possibly contribute to a better understanding of pain and dysfunction and provide real solutions to real problems. Even when he would not necessarily agree with all suggested remedies, he maintained an open mind and was able to take a step back and consider the bigger picture. For example, Leon was not a big fan of dry needling, yet, he valued the importance of this approach and encouraged the inclusion of dry needling papers in this review article and in his journal. The Journal of Bodywork and Movement Therapies became his baby and, considering the growth of the journal, there is no question that Leon's intense focus and efforts are appreciated by many around the globe. We wish to extend our condolences to Leon's wife Alkmini and daughter Sasha. He will surely be missed, but we can find peace in knowing that his legacy will stay with us forever. In this issue, we have included several basic myofascial pain research articles. As usual, dry needling (DN) studies and case reports are the most commonly referenced papers, but we also included neuroscience and electromyography studies, sleep studies, interrater reliability studies, and case reports of adverse events.

An evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool): Concurrent, face and content validity

Purpose

To investigate the concurrent, face and content validity of an evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool).

Methods

1) Concurrent validity of the MAP-BC evaluation tool was investigated by exploring correlations (Spearman’s rank Correlation Coefficient) between the subjective scores (0 –no adhesions to 3 –very strong adhesions) of the skin level using the MAP-BC evaluation tool and objective elasticity parameters (maximal skin extension and gross elasticity) generated by the Cutometer Dual MPA 580. Nine different examination points on and around the mastectomy scar were evaluated. 2) Face and content validity were explored by questioning therapists experienced with myofascial therapy in breast cancer patients about the comprehensibility and comprehensiveness of the MAP-BC evaluation tool.

Results

1) Only three meaningful correlations were found on the mastectomy scar. For the most lateral examination point on the mastectomy scar a moderate negative correlation (-0.44, p = 0.01) with the maximal skin extension and a moderate positive correlation with the resistance versus ability of returning or ‘gross elasticity’ (0.42, p = 0.02) were found. For the middle point on the mastectomy scar an almost moderate positive correlation with gross elasticity was found as well (0.38, p = 0.04) 2) Content and face validity have been found to be good. Eighty-nine percent of the respondent found the instructions understandable and 98% found the scoring system obvious. Thirty-seven percent of the therapists suggested to add the possibility to evaluate additional anatomical locations in case of reconstructive and/or bilateral surgery.

Conclusions

The MAP-BC evaluation tool for myofascial adhesions in breast cancer patients has good face and content validity. Evidence for good concurrent validity of the skin level was found only on the mastectomy scar itself.

Consensus in Traditional Chinese Medical Diagnosis in Open Populations

Objectives: An acceptable level of diagnostic agreement is a prerequisite for consistent administration of treatment. It is critical for investigating effectiveness of different treatment approaches using multiple practitioners. To the best of our knowledge, no previous investigation of diagnostic consensus using open populations in Chinese medicine (CM) has been reported. Investigations restricted to individual medical conditions, such as have been usually studied, do not reveal any information as to what occurs in real world clinical settings. This knowledge gap led to the current study being conducted. Design/Location/Subjects/Interventions: Investigating diagnostic agreement specifically in Traditional Chinese Medicine (TCM) in an open population, two or three practitioners diagnosed 35 subjects at the University of Technology, Sydney (UTS), TCM clinic. The practitioners were restricted to a list of the 56 most frequently used TCM diagnoses at the UTS clinic. Up to three diagnostic patterns per subject could be selected, with nominated patterns scored between 1 and 5. Outcome measures: Agreement was determined with two criteria, both expressed as simple percentages: pattern and linearly weighted agreements. Results: The results showed that 23% of practitioners obtained pattern agreement, while 19% demonstrated weighted agreement. Conclusion: There appears to be very low diagnostic agreement between practitioners. This is an important finding. If unchallenged by further investigation, the recognition of such poor diagnostic consensus may lead to rejection of TCM theory before it has been adequately assessed. Diagnostic agreement must be improved so that future investigations into treatment effectiveness or mechanisms of action are made on a valid basis. Additionally, the current TCM diagnostic format must be altered to allow the application of chance-removed statistics or the calculation of a standard error with open populations. This article is the first of a series of three that report problems in TCM diagnostic reliability and proposes solutions to the issues outlined.