Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis

Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: A case report

Key Clinical Message

The use of DN to the muscular trigger points and distal periosteal enthesis of the levator scapulae may be a useful adjunct intervention within a multi-modal plan of care for the management of work-related chronic tension-type headaches associated with LSS.

Abstract

Chronic tension-type headaches (CTTH) have a lifetime prevalence of 42% and account for more lost workdays than migraine headaches. Dry needling (DN) is being increasingly used by physical therapists in the management of CTTH; however, to date, the supporting evidence is limited. The purpose of this case report was to describe how three sessions of DN targeting myofascial trigger points in the levator scapulae (LS) muscle and its distal enthesis was used to treat a 63-year-old male patient who presented with work-related CTTH associated with levator scapulae syndrome (LSS). The patient was treated for five visits over the course of 2 months. At discharge and 6-month follow-up, the patient reported full resolution of symptoms. Self-report outcomes included the numeric pain rating scale and the Neck Disability Index. The use of DN to the LS muscle and its distal enthesis may be a valuable addition to a multi-modal plan of care in the treatment of work-related CTTH associated with LSS.

Myotonometry is Capable of Reliably Obtaining Trunk and Thigh Muscle Stiffness Measures in Military Cadets During Standing and Squatting Postures

INTRODUCTION

Low back and lower extremity injuries are responsible for the highest percentage of musculoskeletal injuries in U.S. Army soldiers. Execution of common soldier tasks as well as army combat fitness test events such as the three-repetition maximum deadlift depends on healthy functioning trunk and lower extremity musculature to minimize the risk of injury. To assist with appropriate return to duty decisions following an injury, reliable and valid tests and measures must be applied by military health care providers. Myotonometry is a noninvasive method to assess muscle stiffness, which has demonstrated significant associations with physical performance and musculoskeletal injury. The aim of this study is to determine the test-retest reliability of myotonometry in lumbar spine and thigh musculature across postures (standing and squatting) that are relevant to common soldier tasks and the maximum deadlift.

MATERIALS AND METHODS

Repeat muscle stiffness measures were collected in 30 Baylor University Army Cadets with 1 week between each measurement. Measures were collected in the vastus lateralis (VL), biceps femoris (BF), lumbar multifidus (LM), and longissimus thoracis (LT) muscles with participants in standing and squatting positions. Intraclass correlation coefficients (ICCs3,2) were estimated, and their 95% CIs were calculated based on a mean rating, mixed-effects model.

RESULTS

The test-retest reliability (ICC3,2) of the stiffness measures was good to excellent in all muscles across the standing position (ICCs: VL = 0.94 [0.87-0.97], BF = 0.97 [0.93-0.98], LM = 0.96 [0.91-0.98], LT = 0.81 [0.59-0.91]) and was excellent in all muscles across the squatting position (ICCs: VL = 0.95 [0.89-0.98], BF = 0.94 [0.87-0.97], LM = 0.96 [0.92-0.98], LT = 0.93 [0.86-0.97]).

CONCLUSION

Myotonometry can reliably acquire stiffness measures in trunk and lower extremity muscles of healthy individuals in standing and squatting postures. These results may expand the research and clinical applications of myotonometry to identify muscular deficits and track intervention effectiveness. Myotonometry should be used in future studies to investigate muscle stiffness in these body positions in populations with musculoskeletal injuries and in research investigating the performance and rehabilitative intervention effectiveness.

Physically Active Adults with Low Back Pain do not Demonstrate Altered Deadlift Mechanics: A Novel Application of Myotonometry to Estimate Inter-Muscular Load Sharing

Background

Rehabilitation clinicians that work with physically active populations are challenged with how to safely return patients back to performing deadlift movements following low back injury. Application of reliable and valid tests and measures to quantify impairments related to low back pain (LBP) enhances clinical decision making and may affect outcomes. Myotonometry is a non-invasive method to assess muscle stiffness which has demonstrated significant associations with physical performance and musculoskeletal injury.

Hypothesis/Purpose

The purpose of this study was to compare the stiffness of trunk (lumbar multifidus [LM] and longissimus thoracis [LT]) and lower extremity (vastus lateralis [VL] and biceps femoris [BF]) muscles between individuals with and without LBP during the lying, standing, and deadlifting body positions.

Study Design

Cross-sectional cohort comparison.

Methods

Muscle stiffness measures were collected in the VL, BF, LM, and LT muscles with participants in lying (supine and prone), standing, and the trap bar deadlift position. Separate analyses of covariance were conducted to compare absolute and relative muscle stiffness between the groups for each muscle and condition.

Results

Sixty-eight participants (41 female, 21.3 years, 34 LBP) volunteered for the study. Within the deadlift condition there was a significantly greater increase in the percent-muscle stiffness change in the VL (p = .029, 21.9%) and BF (p = .024, 11.2%) muscles in the control group than in the LBP group. There were no differences in percent-muscle stiffness changes for the standing condition nor were there any absolute muscle stiffness differences between the two groups for the three conditions.

Conclusion

No differences in muscle stiffness were identified in the lying, standing, or deadlifting conditions between participants with and without LBP. Differences in percent stiffness changes were noted between groups for the deadlift position, however the differences were modest and within measurement error. Future studies should investigate the utility of myotonometry as a method to identify LBP-related impairments that contribute to chronic and/or recurrent low back injury.

Level of Evidence

Level 3.

Identification of Myofascial Trigger Point Using the Combination of Texture Analysis in B-Mode Ultrasound with Machine Learning Classifiers

Myofascial pain syndrome is a chronic pain disorder characterized by myofascial trigger points (MTrPs). Quantitative ultrasound (US) techniques can be used to discriminate MTrPs from healthy muscle. In this study, 90 B-mode US images of upper trapezius muscles were collected from 63 participants (left and/or right side(s)). Four texture feature approaches (individually and a combination of them) were employed that focused on identifying spots, and edges were used to explore the discrimination between the three groups: active MTrPs (n = 30), latent MTrPs (n = 30), and healthy muscle (n = 30). Machine learning (ML) and one-way analysis of variance were used to investigate the discrimination ability of the different approaches. Statistically significant results were seen in almost all examined features for each texture feature approach, but, in contrast, ML techniques struggled to produce robust discrimination. The ML techniques showed that two texture features (i.e., correlation and mean) within the combination of texture features were most important in classifying the three groups. This discrepancy between traditional statistical analysis and ML techniques prompts the need for further investigation of texture-based approaches in US for the discrimination of MTrPs.

Myofascial and discogenic origins of lumbar pain: A critical review

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

Myofascial Trigger Point Identification in B-Mode Ultrasound: Texture Analysis Versus a Convolutional Neural Network Approach

OBJECTIVE

Myofascial pain syndrome (MPS) is one of the most common causes of chronic pain and affects a large portion of patients seen in specialty pain centers as well as primary care clinics. Diagnosis of MPS relies heavily on a clinician's ability to identify the presence of a myofascial trigger point (MTrP). Ultrasound can help, but requires the user to be experienced in ultrasound. Thus, this study investigates the use of texture features and deep learning strategies for the automatic identification of muscle with MTrPs (i.e., active and latent MTrPs) from normal (i.e., no MTrP) muscle.

METHODS

Participants (n = 201) were recruited from Toronto Rehabilitation Institute, and ultrasound videos of their trapezius muscles were acquired. This new data set consists of 1344 images (248 active, 120 latent, 976 normal) collected from these videos. For texture analysis, several features were investigated with varying parameters (i.e., region of interest size, feature type and pixel pair relationships). Convolutional neural networks (CNN) were also applied to observe the performance of deep learning approaches. Performance was evaluated based on the classification accuracy, micro F1-score, sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

The best CNN approach was able to differentiate between muscles with and without MTrPs better than the best texture feature approach, with F1-scores of 0.7299 and 0.7135, respectively.

CONCLUSION

The results of this study reveal the challenges associated with MTrP identification and the potential and shortcomings of CNN and radiomics approaches in detail.

The importance of myofascial trigger points in chronic neck pain: An ultrasonography preliminary study

BACKGROUND

Ultrasonographic evaluation of trigger points detected by physical examination in patients with myofascial pain syndrome is being used more frequently in clinical care. However, the sonographic appearance of trigger points, in association with pain and disability, has not been adequately described.

OBJECTIVE

To reveal the presence of trigger points with ultrasonography in those with myofascial pain syndrome and to determine if ultrasound images can help discriminate between demographic and disease characteristics.

METHODS

Fifty-two participants with chronic neck pain (NP) were in this cross-sectional study. The pain intensity was evaluated using a 0-10 cm visual analog scale (VAS). The neck disability index measured the NP-induced disability status of the participants. Ultrasonography was used to measure the thicknesses of the paraspinal muscles and the presence of hypoechoic areas within these muscles.

RESULTS

There was a positive correlation between the VAS scores of the participants and the ultrasonographic detection of myofascial trigger points (MTPs) in the multifidus and middle trapezius muscles (right/left r = .30, p = .027; r = .29, p = .029; r = .32, p = .009, r = .30, p = .011, respectively). These features correlated with the disability levels of the participants and the MTPs on both the right and left sides of the splenius, multifidus, upper trapezius, and middle trapezius (r = .32, p = .028; r = .38, p = .013, r = .25, p = .027; r = .33, p = .016; r = .25, p = .025, r = .32, p = .018, r = .28, p = .013, r = .29, p = .016, respectively). A significant correlation was present between the detection of MTP at ultrasonography and decreased muscle thickness in the relevant muscles (between p = .001 and p = .034).

CONCLUSION

The detection of MTPs with ultrasonography is associated with the severity of pain and disability in those with chronic NP. Features on ultrasound include hypoechoic changes within muscle and reduced muscle thickness associated with MTPs.

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.

Myofascial Pain as an Unseen Comorbidity in Osteoarthritis: A Scoping Review

OBJECTIVE

This review aimed to identify, summarize, and appraise the evidence supporting the coexistence of myofascial pain (MPS) and trigger points (MTrP) in osteoarthritis (OA), and the effectiveness of MTrPs treatments in OA-related pain and physical function outcomes.

METHODS

Three databases were searched from inception to June 2022. We included observational and experimental studies to fulfill our 2 study aims. Two independent reviewers conducted 2-phase screening procedures and risk of bias using checklist tools for cross-sectional, quasi-experimental, and randomized control trials. Patient characteristics, findings of active and latent MTrPs in relevant muscles, treatments, and pain and physical function outcomes were extracted from low-risk bias studies.

RESULTS

The literature search yielded 2898 articles, of which 6 observational and 7 experimental studies had a low bias risk and the data extracted. Active MTrPs in knee OA patients was more evident in the quadriceps and hamstring muscles than in healthy individuals. Dry needling on active MTrPs improved pain and physical function in the short term compared with sham treatment in hip OA patients. In knee OA, dry needling on latent or active MTrPs improved pain and functional outcomes compared with sham needling but did not result in better pain and physical outcomes when combined with a physical exercise program.

DISCUSSION

The presence of active versus latent MTrPs seems to be a more sensitive discriminating feature of OA given that latent is often present in OA and healthy individuals. Dry needling on active MTrPs improved pain and physical function in the short term compared with sham treatment in hip OA patients. However, the small sample size and the few number of studies limit any firm recommendation on the treatment.

REGISTRY

The study protocol was prospectively registered in Open Science Framework (https://doi.org/10.17605/OSF.IO/8DVU3).

The Utility of Myotonometry in Musculoskeletal Rehabilitation and Human Performance Programming

Myotonometry is a relatively novel method used to quantify the biomechanical and viscoelastic properties (stiffness, compliance, tone, elasticity, creep, and mechanical relaxation) of palpable musculotendinous structures with portable mechanical devices called myotonometers. Myotonometers obtain these measures by recording the magnitude of radial tissue deformation that occurs in response to the amount of force that is perpendicularly applied to the tissue through a device's probe. Myotonometric parameters such as stiffness and compliance have repeatedly demonstrated strong correlations with force production and muscle activation. Paradoxically, individual muscle stiffness measures have been associated with both superior athletic performance and a higher incidence of injury. This indicates optimal stiffness levels may promote athletic performance, whereas too much or too little may lead to an increased risk of injury. Authors of numerous studies suggested that myotonometry may assist practitioners in the development of performance and rehabilitation programs that improve athletic performance, mitigate injury risk, guide therapeutic interventions, and optimize return-to-activity decision-making. Thus, the purpose of our narrative review was to summarize the potential utility of myotonometry as a clinical tool that assists musculoskeletal clinicians with the diagnosis, rehabilitation, and prevention of athletic injuries.

Physical testing in patients with acute whiplash-associated disorders: A within session test-retest reliability study

BACKGROUND

People with whiplash-associated disorders (WAD) commonly present with a variety of physical impairments. However, the reliability of physical tests has not been established for patients with acute WAD.

OBJECTIVE

To assess test-retest reliability of different physical tests in acute WAD.

DESIGN

Intra-rater test-retest reliability.

METHODS

Patients with acute WAD were recruited. Physical tests were used to evaluate articular, muscular and neural systems in two blocks of measurements separated by 10 min. Bland-Altman plots were performed to assess intrarater agreement, which included calculation of the mean difference (d) between rates, the 95% CI for d, the standard deviation of the differences and the 95% limits of agreement. Reliability was calculated via the standard error of measurement, the minimal detectable change, percent of agreement, the intraclass-correlation coefficient, and kappa coefficient.

RESULTS

47 patients participated. Test-retest reliability was excellent or good for almost all measures, except for extension ROM, ULTT for the radial nerve, and active cervical extension and upper cervical rotation performed in 4-point kneeling, which presented moderate reliability. Systematic bias was found in cervical ROM in flexion, left and right lateral-flexion, left and right rotation; left ULTT for radial nerve; right trapezius, suboccipitalis and temporalis muscles, left temporalis; C3, both sides of C1-C2, left C3-C4.

CONCLUSION

The majority of physical tests achieved good or excellent test-retest intra-rater reliability when tested in patients with acute WAD. Findings must be considered with caution for those tests which demonstrated systematic bias. Additional research is warranted to evaluate inter-rater reliability.

Pressure Pain Threshold of the Upper Trapezius Trigger Point: A Systematic Review with Meta-Analysis of Baseline Values and Their Modification after Physical Therapy

BACKGROUND

Myofascial trigger points (TrP) are diagnosed upon the presence of clinical signs among which hypersensitivity is considered one of the most important. The detection of the pressure pain threshold (PPT) is used to quantify the degree of hypersensitivity. However, there is a lack of normative data about how hypersensitive a TrP is. Therefore, the objective was to quantify the PPT for myofascial TrP in the upper trapezius muscle and its modification after manual or instrumental physical therapy interventions.

METHODS

A systematic review and meta-analysis were conducted among three databases (MEDLINE, Cochrane Library, and PEDro). Two independent reviewers conducted the electronic search and assessed the methodological quality of the included studies.

RESULTS

Eleven studies with a high-risk bias indicated that the PPT at TrP sites was 105.11 kPa lower (95% CI: -148.93; -61.28) at active TrP sites (Chi-squared = 1.07, df = 1 (p = 0.30), I² = 7%) compared to the PPT of the upper trapezius muscles of healthy subjects. In addition, the PPT of TrP was also lower than the reference values coming from the pain-free population. Moreover, the PPT increased after both manual and instrumental treatment by 28.36 kPa (95% CI: 10.75; 45.96) and 75.49 kPa (95% CI: 18.02; 132.95), respectively.

CONCLUSIONS

The results of the present study show that TrP has a decreased PPT when compared to healthy muscles and that physical therapy may increase the PPT. However, the clinical relevance of this decreased PPT needs to be further elucidated. Further, the high risk of bias in all the retrieved studies undermines the validity of the results.

Myofascial Pain Syndrome in Women with Primary Dysmenorrhea: A Case-Control Study

There is limited information on myofascial trigger points (MTrPs) and specific symptoms of chronic pelvic pain and, more specifically, dysmenorrhea. The objective of this study was to determine whether patients suffering from primary dysmenorrhea present alterations in mechanosensitivity and pain patterns, and greater presence of MTrPs in the abdominal and pelvic floor muscles. A case-control study was carried out with a total sample of 84 participants distributed based on primary dysmenorrhea and contraceptive treatment. The sample was divided into four groups each comprising 21 women. Data on pain, quality of life, and productivity and work absenteeism were collected; three assessments were made in different phases of the menstrual cycle, to report data on pressure pain threshold, MTrP presence, and referred pain areas. One-way ANOVA tests showed statistically significant differences (p < 0.01) between the groups, for the Physical Health domain and the total score of the SF-12 questionnaire, and for all the domains of the McGill questionnaire; but no significant differences were found in the data from the WPAI-GH questionnaire. Statistically significant data (p < 0.01) were found for mechanosensitivity in the abdominal area and limbs, but not for the lumbar assessment, within the group, with very few significant intergroup differences. The frequency of active MTrPs is higher in the groups of women with primary dysmenorrhea and during the menstrual phase, with the prevalence of myofascial trigger points of the iliococcygeus muscle being especially high in all examination groups (>50%) and higher than 70% in women with primary dysmenorrhea, in the menstrual phase, and the internal obturator muscle (100%) in the menstrual phase. Referred pain areas of the pelvic floor muscles increase in women with primary dysmenorrhea.

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

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

Ultrasound Confirmation of the Multiple Loci Hypothesis of the Myofascial Trigger Point and the Diagnostic Importance of Specificity in the Elicitation of the Local Twitch Response

The literature has hypothesized that a trigger point (TrP) area consists of a hyperperfused contracture knot with smaller hypoperfused TrPs within the contracture knot. By contrast, the only published ultrasound image of a TrP has it labeled hypoechoic (i.e., hyperperfused) with no commentary regarding smaller speckles of hypoperfusion within. Furthermore, the lack of clarity in objective definition of the terms associated with the TrP (namely, the palpable “contracture knot” and smaller nonpalpable “trigger point”) has led to unnecessary communication difficulties between and among clinicians and researchers. In this case series of three muscles across two patients, by using high-definition musculoskeletal ultrasound imaging technology, we present what we believe to be the first reliable capture of palpable hypoechoic (e.g., hypoperfused) contracture knots (previously mislabeled as a hypoechoic TrP), and a visual support of the multiple loci hypothesis first proposed by Hong and Simons—the first reliable confirmation of the hyperechoic (i.e., hypoperfused) TrP within. Initially proposed by a histological study and supported by microdialysis study, this case series lends further support for the multiple loci hypothesis through visual confirmation of palpable hypoechoic contracture knots, with smaller hypoechoic TrPs “speckles” within.

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.

Assessment of Myofascial Trigger Points via Imaging: A Systematic Review

ABSTRACT

This study systematically reviewed the published literature on the objective characterization of myofascial pain syndrome and myofascial trigger points using imaging methods. PubMed, Embase, Ovid, and the Cochrane Library databases were used, whereas citation searching was conducted in Scopus. Citations were restricted to those published in English and in peer-reviewed journals between 2000 and 2021. Of 1762 abstracts screened, 69 articles underwent full-text review, and 33 were included. Imaging data assessing myofascial trigger points or myofascial pain syndrome were extracted, and important qualitative and quantitative information on general study methodologies, study populations, sample sizes, and myofascial trigger point/myofascial pain syndrome evaluation were tabulated. Methodological quality of eligible studies was assessed based on the Quality Assessment of Diagnostic Accuracy Studies criteria. Biomechanical properties and blood flow of active and latent myofascial trigger points assessed via imaging were found to be quantifiably distinct from those of healthy tissue. Although these studies show promise, more studies are needed. Future studies should focus on assessing diagnostic test accuracy and testing the reproducibility of results to establish the best performing methods. Increasing methodological consistency would further motivate implementing imaging methods in larger clinical studies. Considering the evidence on efficacy, cost, ease of use and time constraints, ultrasound-based methods are currently the imaging modalities of choice for myofascial pain syndrome/myofascial trigger point assessment.

A reliability study of a novel visual ischemic palpation scale in an experimental setting

BACKGROUND

Manual palpation is an important part of the clinical examination and generally it has low reliability. The aim of this study was to assess the reliability of a novel method for discriminating 3 different levels of palpation force.

METHODS

This reliability study included 96 healthy physiotherapists and physiotherapy students, who have been taught a new palpation graduated procedure called Visual Ischemic Palpatory Scale (VIPS), aimed to classify the applied pressure based on the finger's ischemia. Force was recorded by a force measurement system putting sensor over a rigid surface. To study the characteristic of VIPS the analysis of variance (ANOVA), Spearman rank correlation coefficient, Intraclass Correlation Coefficient (ICC), Standard Error of Measurements (SEM), and Minimal Detectable Change (MDC) were calculated.

RESULTS

Three distinct degrees were found with distinct forces expression: 1st degree 76.04 g (95% CI 65.86-86.22), 2nd degree 307.87 g (95% CI 263.29-352.44) and 3rd degree 1319.48 g (CI 1204.73-1434.23). Male participants significantly recorded a greater force than females. Good to excellent reliability across degrees were found (0.89 [95% CI: 0.82-0.97]), and final agreement found that more than 65.6% of sample recorded a force in the cut-offs identified. SEM values became bigger as the recorded force increased and MDC were equal to 48.94 g, 188.73 g, and 379.24 g for 1st, 2nd, and 3rd degree, respectively.

CONCLUSIONS

VIPS would appear to have three distinct degrees, sex dependent, with specific force expression for each degree and a good to excellent intra-rater reliability, but a poor agreement between raters.

Re-Examining Myofascial Pain Syndrome: Toward Biomarker Development and Mechanism-Based Diagnostic Criteria

PURPOSE OF REVIEW

We discuss the need for a mechanism-based diagnostic framework with a focus on the development of objective measures (e.g., biomarkers) that can potentially be added to the diagnostic criteria of the syndrome. Potential biomarkers are discussed in relation to current knowledge on the pathophysiology of myofascial pain syndrome (MPS), including alterations in redox status, inflammation, and the myofascial trigger point (MTrP) biochemical milieu, as well as imaging and neurophysiological outcomes. Finally, we discuss the long-term goal of conducting a Delphi survey, to assess the influence of putative MPS biomarkers on clinician opinion, in order to ultimately develop new criteria for the diagnosis of MPS.

RECENT FINDINGS

Myofascial pain syndrome (MPS) is a prevalent healthcare condition associated with muscle weakness, impaired mood, and reduced quality of life. MPS is characterized by the presence of myofascial trigger points (MTrPs): stiff and discrete nodules located within taut bands of skeletal muscle that are painful upon palpation. However, physical examination of MTrPs often yields inconsistent results, and there is no gold standard by which to diagnose MPS. The current MPS diagnostic paradigm has an inherent subjectivity and the absence of correlation with the underlying pathophysiology. Recent advancements in ultrasound imaging, systemic biomarkers, MTrP-specific biomarkers, and the assessment of dysfunction in the somatosensorial system may all contribute to improved diagnostic effectiveness of MPS.

Elasticity of neck muscles in cervicogenic headache

AIM

To compare the elasticity of the sternocleidomastoid and trapezius muscles in patients with cervicogenic headache and in healthy volunteers.

METHODS

The medical history of 23 patients with cervicogenic headache was taken with a focus on pain characteristics. Elasticity of the sternocleidomastoid and trapezius muscles was measured by using shear wave elastography. Results were then compared with 23 healthy volunteers.

RESULTS

The sternocleidomastoid muscle was significantly stiffer in patients with cervicogenic headache compared to healthy volunteers. The stiffness increased gradually from the parasternal area, where it was negligible, to the area near the mastoid process where it reached over 20 kPa. There was no difference in the stiffness of the trapezius muscle. The stiffness of the sternocleidomastoid muscle does show a significant dependence on headache characteristics (e.g., laterality, severity, or frequency).

CONCLUSION

The results of this pilot study show that patients with cervicogenic headache have a higher stiffness of the sternocleidomastoid muscle than healthy volunteers. These findings suggest that elastography could be used as a diagnostic tool in cervicogenic headache.

The utilization and effects of filiform dry needling in the management of tendinopathy: a systematic review

Background: Tendinopathy is frequently associated with pain, soft tissue impairments and muscle performance limitations. Dry needling (DN) incorporates a fine filiform needle to penetrate the skin and underlying soft tissue in an effort to decrease pain and improve function. While injectable interventions and gauged-needle tendon fenestration for tendinopathy has been reviewed, DN for tendinopathy has yet to be synthesized.Objective: To systematically review the utilization and effects of DN for tendinopathy.Methods: Six electronic databases (PubMed, CINAHL, Scopus, SportDiscus, PEDro and the Cochrane Library) were searched from inception through August 15, 2020, using appropriate keywords and relevant synonyms.Results: After screening 462 articles, 10 studies met inclusion criteria. Study designs included case reports, case series, and randomized clinical trials. DN was used in isolation in 3/10 studies and as part of a multimodal approach in 7/10 studies. DN was associated with improved pain, function, muscle performance and perceived improvement in each study evaluating the relevant outcome. Conflicting results were found in comparative studies evaluating DN.Conclusions: DN may be a useful adjunctive treatment in the conservative management of tendinopathy, although its discrete effect is unclear. Very Low-quality evidence and methodological limitations suggest further investigation is warranted.

Immediate decrease of muscle biomechanical stiffness following dry needling in asymptomatic participants

BACKGROUND

Biomechanical muscle stiffness has been linked to musculoskeletal disorders. Assessing changes in muscle stiffness following DN may help elucidate a physiologic mechanism of DN. This study characterizes the effects of dry needling (DN) to the infraspinatus, erector spinae, and gastrocnemius muscles on biomechanical muscle stiffness.

METHOD

60 healthy participants were randomized into infraspinatus, erector spinae, or gastrocnemius groups. One session of DN was applied to the muscle in standardized location. Stiffness was assessed using a MyotonPRO at baseline, immediately post DN, and 24 h later. The presence of a localized twitch response (LTR) during DN was used to subgroup participants.

RESULTS

A statistically significant decrease in stiffness was observed in the gastrocnemius, the LTR gastrocnemius, and the LTR erector spinae group immediately following DN treatment. However, stiffness increased after 24 h. No significant change was found in the infraspinatus group.

CONCLUSIONS

DN may cause an immediate, yet transitory change in local muscle stiffness. It is unknown whether these effects are present in a symptomatic population or related to improvements in clinical outcomes. Future studies are necessary to determine if a decrease in biomechanical stiffness is related to improvement in symptomatic individuals.

The reliability in determining the deep fascia displacement of the upper trapezius during cervical movement: A pilot study

BACKGROUND

Restricted shoulder fascia displacement may be an etiological factor for myofascial pain syndrome. A diagnostic ultrasound video can follow deep fascia displacement during active cervical movements. Trackers can be applied to videos to convert deep fascia displacement into data points. This study reports on assessors' reliability in evaluating direction and quantifying upper trapezius' deep fascia displacement during active cervical movements.

METHODS

PT-Sonographer 1 recorded deep fascia displacement of upper trapezius for three sets using HS1 Konica Minolta diagnostic ultrasound. The recording sequence used was cervical flexion, extension, right lateral flexion, left lateral flexion, right rotation, and left rotation. The three assessors used the tracker to determine direction of deep fascia displacement. PT-Sonographer 1 used the tracker three times in quantifying deep fascia displacement. Intraclass correlation coefficient and Kappa determined the assessors' intra-tester and inter-tester reliability.

RESULTS

Ten participants were included in the study with a mean±(SD) age of 37±(6). All the assessors had acceptable intra-tester reliability in determining deep fascia displacement on tracker (ICC≥0.40). All assessors had clinically unacceptable inter-tester reliability in determining deep fascia displacement when tracking right rotation (ICC < 0.40). PT-Sonographer 1 had clinically unacceptable intra-tester reliability in determining deep fascia displacement when tracking left rotation (ICC<0.40).

CONCLUSION

We report clinically acceptable assessors' reliability in determining direction and total deep fascia displacement when tracking diagnostic ultrasound videos of cervical flexion, extension, and lateral flexion. Checking for reliable deep fascia displacements may distinguish MPS from non-MPS individuals increasing the utility of diagnostic ultrasound machine and tracker in clinical practice.

Neck associated factors related to migraine in adolescents with painful temporomandibular disorders

OBJECTIVE

Migraine is a comorbidity of painful temporomandibular disorders (TMDs). Both migraine and painful TMD have associations with neck pain and head posture. The aim of this study was to clarify the role of neck pain and head posture on the association between migraine and painful TMD in adolescents.

MATERIALS AND METHOD

In total 314 adolescents were included: 235 adolescents with only painful TMD (pTMD) and 79 adolescents with painful TMD and migraine (TMDMIG). Adolescents were diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders and International Classification of Headache Disorders, 3rd edition. Head postures were identified using lateral cephalograms. Myofascial trigger points (TrPs) were evaluated in the temporalis, masseter, trapezius, sternocleidomastoid, sub-occipitalis, and splenius capitis muscles.

RESULTS

Multivariate logistic regression analysis confirmed the associations among the orofacial pain duration, number of active TrPs in the trapezius muscles, intensity of neck pain, and distance between the occiput and atlas and migraine in adolescents with TMD. The relationships among intensity of neck pain, number of TrPs in the cervical muscles, and head posture were more prominent in the TMDMIG than those in the pTMD.

CONCLUSION

Neck associated factors seemed to have relevance with migraine in adolescents with painful TMD.

Accuracy of rib palpation for dry needling of deep periscapular musculature, measured with ultrasound

INTRODUCTION

Dry needling of the periscapular musculature is a procedure commonly performed by physical therapists. Needling of the deep musculature may be challenging, and use of a thoracic rib as a "backstop" is often applied to prevent inadvertent puncture of the pleura. The aim of this study was to: 1) To examine the accuracy rate of experienced physical therapists in identifying a mid-scapular thoracic rib using palpation, 2) to understand patient characteristics that affect the accuracy rate, and 3) to examine if therapist confidence levels were associated with palpatory accuracy.

METHODS

Two experienced physical therapists attempted to palpate a thoracic rib in the mid-scapular region of healthy participants (n = 101 subjects, 202 ribs), and self-reported their level of confidence in an accurate palpation. Their accuracy was verified with ultrasonography.

RESULTS

The two physical therapists were accurate on 73.3% of palpations and did not differ in accuracy (72.0% vs. 75.0%, p = 0.747). The only ultrasonographic or subject characteristic measurement that correlated with improved accuracy was a reduced muscle thickness (p = 0.032). Therapists' self-reported confidence levels did not correlate to actual accuracy (p = 0.153).

DISCUSSION

Physical therapists should be aware that palpation of a thoracic rib may not be as accurate as it may seem. The greater thickness of muscle in the area reduces the accuracy of accurate palpation.

CONCLUSION

Dry needling of the periscapular muscles should be done with caution if using a rib as a "blocking" technique.

Diffuse central sensitization in low back patients: A secondary analysis of cross-sectional data including tender point examination and magnetic resonance imaging of the lumbar spine

Consistency between back pain intensity and degenerative changes on magnetic resonance imaging (MRI) of the lumbar spine is poor. This study aimed to show whether tender point (TP) examination, used as a test for diffuse central sensitization, may add valuable information to clinical assessment of patients with low back pain (LBP).This was a cross-sectional study including 141 patients with LBP on sick leave. Baseline measures comprised back pain, leg pain intensity, and LBP examination including TP examination. Degenerative MRI findings were assessed in a standardized manner and blinded for clinical data. The number of TPs was analyzed in relation to sex, widespread pain, radiculopathy, pain duration, and degenerative changes on MRI.The number of TPs was positively associated with the female sex, widespread pain, and pain duration. It was negatively associated with degenerative manifestations and radiculopathy, the latter displaying a low level similar to that of the general population. A positive association between back pain intensity and TPs was present in patients with and without radiculopathy and in patients with substantial degenerative changes. Men with >7-8 TPs and women with >10-11 TPs had more back pain and similar or fewer degenerative changes than patients with few TPs (<3 and <6 TPs, respectively), thereby identifying 34% to 44% of patients with nonspecific LBP and 5% to 8% of patients with radiculopathy, respectively, with disproportionate back pain in relation to degenerative changes.Supplemental TP examination improved clinical and MRI evaluation of patients with LBP. By using gender-specific cut points, patients with disproportionate back pain were identified, presumably indicating diffuse central sensitization.

The Case for Comorbid Myofascial Pain-A Qualitative Review

Myofascial pain syndrome is widely considered to be among the most prevalent pain conditions, both in the community and in specialized pain clinics. While myofascial pain often arises in otherwise healthy individuals, evidence is mounting that its prevalence may be even higher in individuals with various comorbidities. Comorbid myofascial pain has been observed in a wide variety of medical conditions, including malignant tumors, osteoarthritis, neurological conditions, and mental health conditions. Here, we review the evidence of comorbid myofascial pain and discuss the diagnostic and therapeutic implications of its recognition.

The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients

INTRODUCTION

The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination.

OBJECTIVES

The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function.

METHODS

We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions.

RESULTS

Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed.

CONCLUSION

Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.

A critical overview of the current myofascial pain literature - January 2020

We are starting 2020 with 6 basic research studies, 9 review articles, 14 dry needling/injection studies, and one manual therapy paper for a total of 30 new papers. Topics range from studies on mechanisms, inflammatory mediators in myofascial pain, fascia, screening, Platelet-rich plasma intramuscular injections, and temporal summation to clinical studies on patients with tension-type headache, chronic pelvic pain, knee osteoarthritis, plantar fasciitis, generalized musculoskeletal pain, neck pain, breast cancer, tendinopathies, thoracic outlet syndrome, and canine dry needling, among others.

Short-Term Effects of PENS versus Dry Needling in Subjects with Unilateral Mechanical Neck Pain and Active Myofascial Trigger Points in Levator Scapulae Muscle: A Randomized Controlled Trial

Procedures such as dry needling (DN) or percutaneous electrical nerve stimulation (PENS) are commonly proposed for the treatment of myofascial trigger points (MTrP). The aim of the present study is to investigate if PENS is more effective than DN in the short term in subjects with mechanical neck pain. This was an evaluator-blinded randomized controlled trial. Subjects were recruited through announcements and randomly allocated into DN or PENS groups. Pain intensity, disability, pressure pain threshold (PPT), range of motion (ROM), and side-bending strength were measured. The analyses included mixed-model analyses of variance and pairwise comparisons with Bonferroni correction. The final sample was composed of 44 subjects (22 per group). Both groups showed improvements in pain intensity (ηp2 = 0.62; p < 0.01), disability (ηp2 = 0.74; p < 0.01), PPT (ηp2 = 0.79; p < 0.01), and strength (ηp2 = 0.37; p < 0.01). The PENS group showed greater improvements in disability (mean difference, 3.27; 95% CI, 0.27-6.27) and PPT (mean difference, 0.88-1.35; p < 0.01). Mixed results were obtained for ROM. PENS seems to produce greater improvements in PPT and disability in the short term.

Improving characterization and diagnosis quality of myofascial pain syndrome: a systematic review of the clinical and biomarker overlap with delayed onset muscle soreness

INTRODUCTION

Myofascial pain syndrome (MPS) is one of the most common conditions of chronic musculoskeletal pain, yet its mechanisms are still poorly understood. Delayed Onset Muscle Soreness (DOMS) is also a regional pain syndrome that has clinical similarities to MPS, but has been better investigated. Emerging research suggests that DOMS may be a valid experimental model for studying MPS; however, a comparison of the similarities and differences of these two conditions has previously not been performed. Herein, we aimed to identify the similarities and differences in the clinical features and biomarkers between DOMS and MPS in order to better define MPS and identify future areas of (DOMS-informed) MPS research.

EVIDENCE ACQUISITION

In order to identify similarities and differences in the clinical manifestation and biomarkers of DOMS and MPS, scoping literature searches were performed using Medline (1965-2019), Embase (1966-2019) and Central (1966-2019) databases. Fifty-three full-text articles were reviewed out of the 2836 articles retrieved in the search.

EVIDENCE SYNTHESIS

A scoping review of the literature demonstrated that DOMS and MPS similarly present as conditions of musculoskeletal pain that are associated with decreased strength and limited range of motion. However, while taut bands and discrete tender spots were described in DOMS, none of the studies reviewed have characterized whether these tender points represent the classic myofascial trigger point phenomenon observed in MPS. Certain systemic circulation biomarkers, including inflammatory cytokines and growth factors, were commonly elevated in MPS and DOMS; further research is needed to determine if other biomarkers that are currently characterized in DOMS are useful to enhance the clinical evaluation of MPS.

CONCLUSIONS

DOMS and MPS share clinical and biomarker similarities suggesting that DOMS may be a useful model for studying MPS.

Inter and Intra Operator Reliability of Motor and Palpation Evaluation in Fascial Manipulation in individuals with coxarthrosis

OBJECTIVE

An inter and intra rater reliability (INTERR and INTRAR) study was designed.

METHODS

71 subjects, with primary hip coxarthrosis, were included and randomly divided in a study group (SG= 36) and a control group (CG= 35) to assess the efficacy of the Fascial Manipulation® (FM®) method. The primary objective was the assessment of INTERR and INTRAR about movement verification (MV) and palpation verification (PV) of FM® performed by two physiotherapists (PtA and PtB). The secondary objective was evaluate the efficacy of FM® through MV, PV and pain score. Pain was assessed using the Numeric Rating Scale (NRS). SG received three weekly sessions of FM® byPtA. PtB re-evaluated all the subjects at the end of the study.

RESULTS

Results of the INTERR analysis showed for SG: MV (ICC= 0.92, k= 72.7%); PV (ICC= 0.91, k= 75.7%). For CG : MV (ICC= 0.95, k= 84.2%); PV (ICC= 0.90, k= 75%). Results of the INTRAR analysis for SG reported: MV (ICC= 0.82, k= 74,8%); PV (ICC= 0.60, k= 46.8%); for CG: MV (ICC= 0.93, k= 78.7%); PV (ICC= 0.84, k= 53.3%). Statistical significance were reported in NRS (p = 0.001), MV (p = 0.0003) and PV (p < 0.0001) with better results for SG using "Intention To Treat" method.

DISCUSSION

This study demonstrates that FM® assessment procedures have a high reliability even if applied by practitioners with basic experience. Furthermore FM® treatment can improve pain and ROM in individuals with primary coxarthrosis.

Feasibility of a Support Vector Machine Classifier for Myofascial Pain Syndrome: Diagnostic Case-Control Study

OBJECTIVES

Myofascial pain syndrome (MPS) is the most common cause of chronic pain worldwide. The diagnosis of MPS is subjective, which has created a need for a robust quantitative method of diagnosing MPS. We propose that using a support vector machine (SVM) along with ultrasound (US) texture features can differentiate between healthy and MPS-affected skeletal muscle.

METHODS

B-mode US video data were collected in the upper trapezius muscle of healthy (29) participants and patients with active (21) and latent (19) MPS, using an acquisition method outlined in previous works. Regions of interest were extracted and filtered to obtain a unique set of 917 images where texture features were extracted from each region of interest to characterize each image. These texture features were then used to train 4 separate binary SVM classifiers using nested cross-validation to implement feature selection and hyperparameter tuning. The performance of each kernel was estimated on the data and validated through testing on a final holdout set.

RESULTS

The radial basis function kernel classifier had the greatest Matthews correlation coefficient performance estimate of 0.627 ± 0.073 (mean ± SD) along with the largest area under the curve of 91.0% ± 3.0%. The final holdout test for the radial basis function classifier resulted in 86.96 accuracy, a Matthews correlation coefficient of 0.724, 88% sensitivity, and 86% specificity, validating our earlier performance estimates.

CONCLUSIONS

We have demonstrated that specific US texture features that have been used in other computer-aided diagnostic literature are feasible to use for the classification of healthy and MPS muscle using a binary SVM classifier.

Ultrasound imaging for sarcopenia, spasticity and painful muscle syndromes

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

A randomized clinical trial comparing non-thrust manipulation with segmental and distal dry needling on pain, disability, and rate of recovery for patients with non-specific low back pain

Objective: The purpose of this study was to examine the within and between-group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP). Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n = 30) or NTM (n = 35) for six sessions over 3 weeks. Outcomes collected included the oswestry disability index (ODI), patient specific functional scale (PSFS), numeric pain rating scale (NPRS), and pain pressure thresholds (PPT). At discharge, patients perceived recovery was assessed. Results: A two-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p = 0.26), ODI (p = 0.57), NPRS (p = 0.69), and PPT (p = 0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p = 0.018), ODI (14.5% [10.0%, 19.0%], p = 0.015), NPRS (2.2 [1.5, 2.8], p = 0.009), but not for PPT (3.3 [0.5, 6.0], p = 0.20). Discussion: The between-group effects were neither clinically nor statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcomes tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP. Level of evidence: 1b.

International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study

Objective

There is no consensus on the essential diagnostic criteria for diagnosing a trigger point (TrP). In fact, a variety of diagnostic criteria are currently being used. Our aim was to conduct a Delphi panel to achieve an international consensus on the cluster of criteria needed for the TrP diagnosis to reach a consensus on the definition of active and latent TrPs and to clarify different clinical considerations about TrPs.

Methods

Following international guidelines, an international three-round Delphi survey was conducted. Questions were created based on a systematic literature search of the diagnostic criteria for TrPs.

Results

Sixty experts from 12 countries completed all rounds of the survey. A cluster of three diagnostic criteria was proposed as essential for the TrP diagnosis: a taut band, a hypersensitive spot, and referred pain. Eighty percent of the experts agreed that the referred pain elicited by a TrP can include different sensory sensations and not just pain, that is, pain spreading to a distant area, deep pain, dull ache, tingling, or burning pain. Eighty-four percent of the international experts consistently answered that the main clinical differences between active and latent TrPs are the reproduction of any of the symptoms experienced by a patient and the recognition of pain. No specific location of the pain referral area and TrP location should be expected.

Conclusions

This Delphi panel has produced an expert-based standardized definition of a TrP with a discussion of the clinical components, including the definition of referred pain and the difference between active and latent TrPs, thereby providing a foundation for future research in MPS.

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.

[Diagnosis and interventional treatment of pain syndromes after surgery for degenerative lumbar spine diseases]

Postoperative pain accompanies up to 20% of interventions for degenerative spine diseases (DSDs). The epidemiologic data are contradictory; clinical and radiological diagnostics is often low efficient; capabilities of interventional diagnosis and treatment techniques are poorly understood.

PURPOSE

The study purpose was to investigate the structure of pain syndromes after surgery for DSDs of the lumbar spine, based on complex diagnostics, as well as to evaluate the capabilities of interventional treatment.

MATERIAL AND METHODS

We examined 310 patients with postoperative pain syndromes. Patients with obvious indications for repeated surgery were excluded from the analysis; the remaining patients underwent selective diagnostic blockades followed by interventional (puncture) treatment. A positive outcome was defined as a reduction in pain by 50% on the numerical rating scale (NRS-11), by 20% in the Oswestry index (ODI), and by 8 points in the sciatica bothersomeness index (SBI), with the effect lasting for 12 months. Predictive factors for the risk of pain syndromes were analyzed.

RESULTS

Out of 310 patients, 162 (52.6%) patients had no obvious indications for surgery. Radicular pain was detected in 56 (18.6%) of 310 patients; the positive treatment outcome was achieved in 38 (67.86%) of 56 patients. Facet pain was present in 29 (9.35%) patients; the positive treatment outcome was achieved in 23 (79.31%) patients. Discogenic pain was found in 12 (3.87%) patients; the positive treatment outcome was achieved in 5 (41.63%) patients. sacroiliac joint (SIJ) pain was present in 42 (13.55%) patients; the positive treatment outcome was achieved in 36 (85.71%) patients. Myofascial and competing pain was detected in 12 (3.87%) patients; the causes were not identified in 11 (3.55%) cases. The main risk factors were sagittal balance parameters.

CONCLUSION

Complex diagnostics revealed postoperative pain not associated with surgical causes in 52.6% of cases; the origin of pain was identified in 49.95% of cases. Interventional treatment was effective in 64.81% of cases; failed back surgery syndrome was diagnosed in 16.13% of patients.

Quantitative ultrasound of trapezius muscle involvement in myofascial pain: comparison of clinical and healthy population using texture analysis

PURPOSE

Ultrasound is a non-invasive quantitative method to characterize sonographic textures of skeletal muscles. To date, there is no information available on the trapezius muscle. This study assessed the trapezius muscles of patients with myofascial pain compared with normal healthy participants.

METHODS

The trapezius muscles of 15 healthy and 17 myofascial pain participants were assessed using B-mode ultrasound to obtain 120 images for healthy and 162 images from myofascial pain participants. Texture features such as blob area, count and local binary patterns (LBP) were calculated. Multi-feature classification and analysis were performed using principal component analysis (PCA) and MANOVA to determine whether there were statistical differences.

RESULTS

We demonstrate the two principal components composed of a combination of LBP and blob parameters which explain 92.55% of the cumulative variance of our data set. In addition, blob characteristics were significantly different between healthy and myofascial pain participants.

CONCLUSION

Our study provides evidence that texture analysis techniques can differentiate between healthy and myofascial pain affected trapezius muscles. Further research is necessary to evaluate the nature of these differences.

A Survey of Healthcare Practitioners on Myofascial Pain Criteria

OBJECTIVES

The goal of this study was to assess agreement on signs and symptoms of myofascial pain for chiropractors, physicians, and registered massage therapists.

METHODS

337 healthcare practitioners participated in the survey. The questionnaire probed clinician agreement with the chosen signs and symptoms using a 7-point agreement scale (1 = absolutely agree, 7 = absolutely disagree). Agreement was assessed using intraclass correlation within chiropractor, physician, and registered massage therapist groups and across all groups. Descriptive statistics, including mean response values, were used to assess which signs or symptoms were most often associated with myofascial pain.

RESULTS

There was poor agreement within chiropractors, physicians, and registered massage therapists on the criteria that represent myofascial pain syndrome. Physicians and massage therapists were in agreement on 4 items and disagreed on 2 items. Chiropractors were in agreement on a different set of signs and symptoms relative to physicians and registered massage therapists, and they expressed neutrality on most statements in the questionnaire. Registered massage therapists were in most agreement amongst each other as a group (intraclass correlation coefficient [ICC] = 0.80) relative to chiropractors (ICC = 0.59) and physicians (ICC = 0.51).

DISCUSSION

Our results suggest that there is a lack of agreement within and between healthcare practitioner groups on the signs and symptoms that define myofascial pain syndrome. We suggest the demonstrated variability in diagnostic knowledge be remedied through the establishment and universal use of official validated criteria. Future research should focus on developing criteria specific to myofascial pain syndrome. Finally, knowledge translation strategies may be implemented to increase clinician knowledge of available criteria.

Quantitative Ultrasound Assessment of Myofascial Pain Syndrome Affecting the Trapezius: A Reliability Study

OBJECTIVES

Myofascial pain syndrome is one of the most common causes of chronic pain and is highlighted by the presence of myofascial trigger points. The current practice of diagnosing myofascial pain syndrome among clinicians involves manual detection of myofascial trigger points, which can be inconsistent. However, the detection process can be strengthened with the assistance of ultrasound (US). Therefore, this study aimed to characterize the upper trapezius by using quantitative techniques in healthy asymptomatic individuals with neck pain.

METHODS

Study participants were recruited on the basis of the inclusion and exclusion criteria established, and US images of the trapezius, along the axial and longitudinal orientations, were obtained. Each set was obtained by 2 investigators: experienced and inexperienced personnel.

RESULTS

Fifteen participants were recruited. The mean gray scale US echo intensity distribution obtained was 41.9. A paired t test of the global mean echo intensity value obtained for each image from the US operators did not show any significant difference (P = .77). A t test was performed, comparing the echo intensity of the group of patients with neck pain and healthy control participants, and the difference was found to be significant (P = .052). The median blob area was 2.71. The quartile range for the blob area was 1.72 for the 25th percentile to 4.90 for the 75th percentile.

CONCLUSIONS

This study demonstrated that quantitative analysis of the echo intensity of US images can provide important information. However, further research is necessary to explore the relationships among sex, age, blob area, count, body mass index, regional anatomy, and extent of training or exercise of the particular muscle.