Application of ultrasound-guided trigger point injection for myofascial trigger points in the subscapularis and pectoralis muscles to post-mastectomy patients: a pilot study

Myofascial pain syndrome in patients with cancer: a narrative review

PURPOSE

Myofascial pain syndrome (MPS) is a chronic musculoskeletal pain syndrome. The purpose of this review is to describe the epidemiological and treatment evidence and to address the future research agenda in patients with cancer.

METHODS

A narrative review of previous reports investigating the prevalence and treatment of MPS in the oncology field is presented. The target population is patients with cancer and cancer survivors.

RESULTS

There have been three prospective and two retrospective studies investigating the prevalence of MPS. MPS is as high as 38%-45% in patients with advanced or incurable cancer and 11.9%-44.8% in cancer survivors. A total of nine reports investigated the efficacy of the following interventions: trigger point injection (TPI), myofascial techniques and ischaemic compression. TPI has been reported to be effective in four observational studies. One randomised study reported the efficacy of myofascial techniques, but two randomised studies reported no added beneficial effects of it in breast cancer survivors. Two randomised studies investigated the efficacy of ischaemic compression, but the obtained results were contradictory.

CONCLUSIONS

MPS is highly prevalent. We should know that non-cancer pain is also common in both patients with cancer and survivors. In treating such pain, careful physical examination is essential. Then, non-pharmacological treatment should be considered as well as pharmacotherapy. As evidence regarding MPS in the oncology field is scarce, further research is warranted.

Effect of Adding Transfer Energy Capacitive and Resistive Therapy to Conventional Therapy for Patients With Myofascial Pain Syndrome in Upper Trapezius: A Randomized Clinical Trial

Objective

The purpose of this study was to compare the effect of adding transfer energy capacitive and resistive (TECAR) therapy to conventional therapy on patients' symptoms of myofascial pain syndrome (MPS) in the upper trapezius.

Methods

Fifty patients with MPS in the upper trapezius were randomized into 2 groups. The intervention group received TECAR therapy (capacitive mode, 2 sessions weekly), and conventional treatment comprised of stretching exercise (9 times a day) and medication (acetaminophen and tizanidine) for 3 weeks, and the comparison group received conventional treatment (same as the intervention group) alone. The patients completed the Numeric Pain Scale, Neck Disability Index, and Shoulder Pain and Disability Index before, after, and 1 month after the treatment.

Results

All variables were significantly reduced within both groups by time and treatment separately (P < .001), while a general comparison among the groups showed a significant reduction for all variables in the intervention group compared with the comparison group (P < .05) except for shoulder disability (P = .114). Moreover, the intervention group had better results compared with the comparison group based on the minimal clinically important difference.

Conclusion

A combination of TECAR therapy, exercise, and medication substantially reduced symptom severity for patients with MPS in the upper trapezius when compared to only exercise and medication.

Intramuscular Innervation of the Supraspinatus Muscle Assessed Using Sihler’s Staining: Potential Application in Myofascial Pain Syndrome

Despite the positive effects of botulinum neurotoxin (BoNT) injection into the neural arborized area, there is no anatomical evidence in the literature regarding the neural arborization of the supraspinatus muscle. The present study aimed to define the intramuscular neural arborized pattern of the supraspinatus muscle using the modified Sihler’s staining method to facilitate the establishment of safe and effective injection sites in patients with myofascial pain in the supraspinatus muscle. Seventeen supraspinatus muscles from 15 embalmed cadavers were dissected. Precise suprascapular nerve entry locations were also observed. Intramuscular neural arborization was visualized by Sihler’s staining. The supraspinatus muscle was divided into four portions named A, B, C, and D. The nerve entry points were observed in 88.2% (15 of 17 cases) of section B and 76.5% (13 of 17 cases) of section C of the supraspinatus muscle, respectively. The concentration of intramuscular neural arborization was highest in section B of the supraspinatus muscle, which was the center of the supraspinatus muscle. When the clinician performs a trigger point and a BoNT injection into the supraspinatus muscle, injection within the medial 25–75% of the supraspinatus muscle will lead to optimal results when using small amounts of BoNT and prevent undesirable paralysis.

The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient

BACKGROUND

Breast cancer is the most commonly occurring cancer among women. Among its treatment sequelae is chronic neuropathic pain after breast surgery (CNPBS). Pain management is difficult and classicaly consists in a pharmacological approach, however recent studies have advocated the use of locoregional techniques as adjuvants. Serratus plane block (SPB) has recently emerged as a potential tool for the control of CNPBS. This study aims to evaluate the efficacy and potencial role of the ultrasound-guided SPB on CNPBS.

METHODS

A retrospective analysis was performed on 30 patients with CNPBS refractory to drug therapy, who underwent SPB between 2017-2019. The following parameters were analyzed: basal pain, pain at 24 h, 1 week and at 1 month. The Mann-Whitney test was applied. Statistical significance was considered at the level of p < 0.05. All statistical analysis was performed with SPSS 20.

RESULTS

3 patients were excluded. At 24 h, we report pain improvement (at least 30% reduction on basal pain score) on 20 patients and after 1 week on 12. At 1 month after, 22 patients had improved, from these: 11 improved with no therapeutic adjustment; 11 patients improved with therapeutic adjustment (8 in gabapentinoid monotherapy, 3 with introduction of polytherapy). 5 patients didn't improve.

CONCLUSION

Our study demonstrated SPB as a valid alternative for CNPBS management when pharmacologic therapy has been proven insufficient, with no side effects reported. Randomized studies are needed to assess the magnitude of SPB on CNPBS and to identify the patients who benefit the most from SPB.

Interventional Therapies for Pain in Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.

RECENT FINDINGS

A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.

The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient

BACKGROUND

Breast cancer is the most commonly occurring cancer among women. Among its treatment sequelae is chronic neuropathic pain after breast surgery (CNPBS). Pain management is difficult and classicaly consists in a pharmacological approach, however recent studies have advocated the use of locoregional techniques as adjuvants. Serratus plane block (SPB) has recently emerged as a potential tool for the control of CNPBS. This study aims to evaluate the efficacy and potencial role of the ultrasound-guided SPB on CNPBS.

METHODS

A retrospective analysis was performed on 30 patients with CNPBS refractory to drug therapy, who underwent SPB between 2017-2019. The following parameters were analyzed: basal pain, pain at 24 hours, 1 week and at 1 month. The Mann-Whitney test was applied. Statistical significance was considered at the level of p < 0.05. All statistical analysis was performed with SPSS 20.

RESULTS

3 patients were excluded. At 24 hours, we report pain improvement (at least 30% reduction on basal pain score) on 20 patients and after 1 week on 12. At 1 month after, 22 patients had improved, from these: 11 improved with no therapeutic adjustment; 11 patients improved with therapeutic adjustment (8 in gabapentinoid monotherapy, 3 with introduction of polytherapy). 5 patients didn't improve. CONCLUSIóN: Our study demonstrated SPB as a valid alternative for CNPBS management when pharmacologic therapy has been proven insufficient, with no side effects reported. Randomized studies are needed to assess the magnitude of SPB on CNPBS and to identify the patients who benefit the most from SPB.

Dry Needling and Acupuncture in Treatment of Dance-Related Injuries, MD, and PT Perspectives

Dancers frequently present to health care professionals with musculoskeletal impairments. The role of the health care practitioner, whether physician, physical therapist, or acupuncturist, is to decrease pain and restore function in the short term and to restore adaptive potential and neural connectivity in the long term. When dysfunction is treated, pain improves. Acupuncture and dry needling improve tissue perfusion by improving vasomotor control and can improve strength by removing motor inhibition. Acupuncture and dry needling are safe, complementary modalities aimed at improving the function of the dancer.

Pecs Blocks for Chronic Pain: A Case Report of Successful Postmastectomy Pain Syndrome Management

Mastectomies can be complicated by difficult-to-treat postmastectomy pain syndrome (PMPS) and axillary web syndrome (AWS). We present a case of PMPS and AWS successfully treated with Pecs I and II blocks and trigger point injections. At follow-up after 4 months, our patient reported 70% improvement in pain, movement, function, and discontinuation of opioids. This case presents the utility of a multimodal approach for a patient with pain after mastectomy. This case report is the first-time demonstration of Pecs blocks to treat chronic PMPS.

Treatment and management of myofascial pain syndrome

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

A Comprehensive Review of the Diagnosis, Treatment, and Management of Postmastectomy Pain Syndrome

PURPOSE OF REVIEW

Postmastectomy pain syndrome (PMPS) remains poorly defined, although it is applied to chronic neuropathic pain following surgical procedures of the breast, including mastectomy and lumpectomy in breast-conserving surgery. It is characterized by persistent pain affecting the anterior thorax, axilla, and/or medial upper arm following mastectomy or lumpectomy. Though the onset of pain is most likely to occur after surgery, there may also be a new onset of symptoms following adjuvant therapy, including chemotherapy or radiation therapy.

RECENT FINDINGS

The underlying pathophysiology is likely multifactorial, although exact mechanisms have yet to be elucidated. In this regard, neuralgia of the intercostobrachial nerve is currently implicated as the most common cause of PMPS. Numerous pharmacological options are available in the treatment of PMPS, including gabapentinoids, tricyclic antidepressants, selective serotonin reuptake inhibitors, NMDA receptor antagonists, and nefopam (a non-opioid, non-steroidal benzoxazocine analgesic). Minimally invasive interventional treatment including injection therapy, regional anesthesia, botulinum toxin, and neuromodulation has been demonstrated to have some beneficial effect. A comprehensive update highlighting current perspectives on the treatment of postmastectomy pain syndrome is presented with emphasis on treatments currently available and newer therapeutics currently being evaluated to alleviate this complex and multifactorial condition.

Myofascial component of cancer pain review

BACKGROUND

Pain is a common complaint of cancer patients, experienced by 38%-85% of patients. Some studies have shown a high incidence of myofascial pain syndrome (MPS) in cancer patients.

AIMS

1) To estimate the prevalence of MPS in cancer patients; 2) to examine the efficacy of current treatment options for MPS in cancer patients.

METHODS

Narrative review. PubMed, CINAHL, PEDro, and Google Scholar databases were searched from inception until November 2017, for the keywords: cancer; cancer pain; breast cancer; mastectomy; lumpectomy; myofascial pain; trigger points. Trials of any methodological quality were included. All published material with an emphasis on randomized control trials was analyzed.

RESULTS

MPS is prevalent in cancer patients who suffer from pain, with a prevalence of between 11.9% and 44.8% in those diagnosed either with neck or head or breast cancer. Clinical studies showed conflicting results. Four interventional studies found that specific treatment for MPS may reduce the prevalence of active myofascial trigger points and therefore decrease pain level, sensitivity, and improve range of motion (in shoulder) in cancer patients. Two recent randomized control trials showed that pressure release of trigger points provides no additional beneficial effects to a standard physical therapy program for upper limb pain and function after breast cancer surgery.

CONCLUSIONS

We recommend including the evaluation of myofascial pain in routine clinical examination of cancer patients suffering from pain. Future studies are needed to investigate the long- and short-term effect of MPS treatments in cancer patients.

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

Myofascial trigger points are not an isolated neuromusculoskeletal phenomenon and have been implicated in systemic, visceral, and metabolic pathology, as a side effect of some medications and in the presence of psychological risk factors. This complexity can complicate adequate screening of patients prior to choosing dry needling as a treatment intervention. Regardless of whether clinicians practice in a direct access setting, they should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dry-needling appropriateness, technique chosen, and potential adverse responses to treatment. Of primary concern are conditions that can either manifest with myalgia and/or myopathy or masquerade as a more common musculoskeletal condition. This clinical commentary reviews system-specific considerations and other common disorders that should be screened for and discusses not only whether dry needling is appropriate but comments on technique and dosage considerations when initiating dry needling.

Ultrasound-Guided Dry Needling As a Treatment For Postmastectomy Pain Syndrome - A Case Series of Twenty Patients

CONTEXT

Existing interventions for postmastectomy pain syndrome (PMPS) address the neural component while overlooking a possible myofascial component.

AIM

The aim of the study is to investigate the myofascial contribution to PMPS, by examining the effectiveness of myofascial trigger point release by ultrasound-guided dry needling (USGDN).

PATIENTS AND METHODS

This retrospective review assessed the efficacy of USGDN in addressing myofascial pain in twenty consecutive patients with treatment-refractory PMPS. Patients in Group 1 (n = 16) received USGDN after neural interventions (NIs) such as neuraxial blocks, intrathecal pump implant, or pulsed radiofrequency, while those in Group 2 (n = 4) received USGDN alone. Outcome measures were changes in Numerical Rating Scale (NRS), PainDETECT (PD), Disabilities of Arm, Shoulder, and Hand (DASH), Patient Health Questionnaire-9 (PHQ-9) scores, and opioid use.

RESULTS

In Group 1, the mean (standard deviation) NRS and PD scores (9.6 [0.9] and 28.3 [4.3], respectively, at baseline) reduced to 5.2 (1.1) and 16.1 (3.7) at 1-week post-NI. The post-NI DASH reduction was below the cutoff for clinical relevance (80.9 [10.5] at baseline vs. 71.1 [10.5] post-NI). The opioid dose remained unchanged. Following USGDN, NRS, PD, and DASH scores further reduced to 2.3 (0.8), 6.6 (1.2), and 34.6 (14.4), respectively. Patients receiving USGDN alone also showed reduction in NRS, PD, and DASH (7.8 [1.7], 20.0 [8.0], and 61.0 [14.4] at baseline vs. 1.3 [0.5], 6.0 [1.6], and 22.5 [10.4] post-USGDN, respectively). In all patients, opioid use and PHQ-9 scores reduced only post-USGDN.

CONCLUSIONS

USGDN reduced pain, disability, and opioid use, whereas NI reduced only pain. This suggests a myofascial contribution to pain and disability in PMPS.

Desativação de pontos-gatilho no tratamento da dor miofascial

A síndrome da dor miofascial (SDM) é causa de dor e limitações, sendo bastante prevalente na população. Seu diagnóstico se dá pela apresentação clínica e exame físico, sendo a dor no local o principal sintoma, que conta com uma irradiação característica conforme o músculo acometido. Devido a esta irradiação, a condição pode mimetizar outras situações clínicas comuns e deve ser lembrada como diagnóstico diferencial. Sua identificação e tratamento podem ser feitos de forma simples e o profissional da atenção primária está apto a realizá-los, no entanto, ainda é muito negligenciada, por ser condição pouco estudada. Seu tratamento inclui fármacos, mudanças de estilo de vida, técnicas de fisioterapia e de agulhamento, sendo que este pode ser a seco ou com injeção de substâncias. O agulhamento com infiltração anestésica parece ser técnica eficaz na desativação de pontos-gatilho musculares e aparenta ser superior às demais em alguns estudos, com a vantagem de ser menos doloroso em sua realização. O objetivo deste estudo é realizar uma revisão da literatura sobre a SDM, levando em conta o quadro clínico, o diagnóstico e o tratamento, retratando resultados com diversas técnicas de agulhamento e comparando-as entre si e com demais técnicas.

The role of peripheral afferents in persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial of ultrasound-guided tender point blockade

BACKGROUND

Severe, persistent inguinal postherniorrhaphy pain (PIPP) is a debilitating condition that develops in 2-5% of patients. PIPP may be neuropathic in nature, yet the lesion in the peripheral nervous system has not been located. Most PIPP-patients demonstrate a tender point (TP) in the medial aspect of the inguinal region that triggers pain upon minimal pressure. As TPs may play a role in the pathophysiology of PIPP, the aim of this trial was to investigate the analgesic effects of local anaesthetic TP-blockade.

METHODS

A randomized, double-blind, placebo-controlled, crossover trial was performed in 14 PIPP-patients and six healthy volunteers. All participated in two sessions, seven days apart, receiving 10 ml of 0.25% bupivacaine or normal saline via an ultrasound-guided fascial plane block at the TP. The TP-area was used for pain assessments (at rest, on movement, with 100 kPa pressure-algometry) and quantitative sensory testing (pressure pain thresholds, thermal detection/pain thresholds, supra-threshold heat perception), before and after the TP-blockade.

RESULTS

The median (95% CI) reduction in pain was 63% (44.1 to 73.6%) after bupivacaine compared with 36% (11.6 to 49.7%; P=0.003) after placebo. Significant increases in cool detection (P=0.01) and pressure pain thresholds (P=0.009) with decreases in supra-threshold heat pain perception (P=0.003) were seen after bupivacaine only. In four out of six volunteers, increased thermal and evoked-pain thresholds after bupivacaine compared with placebo, was demonstrated.

CONCLUSIONS

This trial demonstrates that peripheral afferent input from the TP-area is important for maintenance of spontaneous and evoked pain in PIPP.

CLINICAL TRIAL REGISTRATION

NCT02065219.

A critical overview of the current myofascial pain literature - September 2016

This edition of the overview of the current myofascial pain literature includes 24 studies, case reports and systematic and narrative reviews. Surprisingly, five of the 24 papers were difficult to read and interpret mostly because of a poor mastery of the English language. It is somewhat surprising that journal editors and reviewers would accept papers that are needlessly difficult to read and not direct the authors to language services or others who could improve the quality of the writings. Of course, it is exciting that researchers and clinicians from all over the world continue to focus on myofascial pain and attempt to shed new light on the complexity of the problem to improve the clinical decision-making process and eventually clinical approaches and outcomes. There were no new papers on manual therapies, but many focused on dry needling.

Comparison between Steroid Injection and Stretching Exercise on the Scalene of Patients with Upper Extremity Paresthesia: Randomized Cross-Over Study

PURPOSE

To compare the therapeutic effects on upper extremity paresthesia of intra-muscular steroid injections into the scalene muscle with those of stretching exercise only.

MATERIALS AND METHODS

Twenty patients with upper extremity paresthesia who met the criteria were recruited to participate in this single-blind, crossover study. Fourteen of 20 patients were female. The average age was 45.0 ± 10.5 years and duration of symptom was 12.2 ± 8.7 months. Each participant completed one injection and daily exercise program for 2 weeks. After randomization, half of all patients received ultrasound-guided injection of scalene muscles before exercise, while the other was invested for the other patients.

RESULTS

After two weeks, there was a significant decrease of the visual analog scale score of treatment effect compared with baseline in both groups (6.90 to 2.85 after injection and 5.65 to 4.05 after stretching exercise, p<0.01). However, injection resulted in greater improvements than stretching exercise (p<0.01). The number of patients with successful treatment, defined as >50% reduction in post-treatment visual analog scale, was 18 of 20 (90.0%) after injection, compared to 5 of 20 (25.0%) after stretching exercise. There were no cases of unintended brachial plexus block after injection.

CONCLUSION

Ultrasound-guided steroid injection or stretching exercise of scalene muscles led to reduced upper extremity paresthesia in patients who present with localized tenderness in the scalene muscle without electrodiagnostic test abnormalities, although injection treatment resulted in more improvements. The results suggest that symptoms relief might result from injection into the muscle alone not related to blockade of the brachial plexus.