Editorial for Special Issue "Genetic Basis and Epidemiology of Myopathies"

We are pleased to announce a Special Issue on the Genetic Basis and Epidemiology of Myopathies. This Special Issue is collecting papers pertaining to various lines of research focusing on the genetic basis and the epidemiology of myopathies. The Guest Editors' note combines the contributing authors' reviews and findings of relevant research, and we hope that future studies on myopathies will attempt to confirm these findings and, additionally, evaluate supplementary phenotypic and histological expressions of myopathies, as well as genetic factors in their pathogenesis.

Mixed methods analysis of Health-Related Quality of Life in ambulant individuals affected with RYR1-related myopathies pre-post-N-acetylcysteine therapy

PURPOSE

To characterize Health-Related Quality of Life (HRQoL) in ambulant individuals with RYR1-RM and to determine if a qualitative PRO tool (subjective self-assessment) complements PROMIS and Neuro-QoL scales to detect changes in HRQoL in ambulant individuals with RYR1-RM post N-acetylcysteine (NAC) treatment.

METHODS

The study used a mixed methods research (MMR) design applying methodological triangulation. Qualitative data were collected via semi-structured interviews using open-ended questions. Quantitative data were gathered through PROMIS and Neuro-QoL instruments. Additionally, qualitative data were transformed into quantitative data for subjective self-assessment and frequency analyses.

RESULTS

Qualitative results identified five domains and 33 subdomains as areas of interest. The most valuable were the importance of social impacts, the development of several coping strategies, both physical and psychological, and the identification of fatigue and weakness as key symptoms. Data transformation then categorized more than 3100 citations on frequency analyses, globally and by domain, visit, and participant. Regarding quantitative results, there was no clear evidence that any of the three PRO tools captured positive changes as a result of NAC treatment.

CONCLUSION

Qualitative results showed a comprehensive characterization of HRQoL in this population based on a symptom/patient-centered approach. These findings will inform future studies. Furthermore, given the similar findings across our multiple methods and endpoints, the introduction of MMR may be a valuable, complementary approach to clinical trials. MMR may be especially useful to incorporate in order to address and follow the FDA's guidance and prioritization on the inclusion of affected individuals' perspectives in clinical trials.

Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases

INTRODUCTION

In adults, muscle disease (MD) is often a chronic long-term condition with no definitive cure. It causes wasting and weakness of the muscles resulting in a progressive decline in mobility, alongside other symptoms, and is typically associated with reduced quality of life (QoL). Previous research suggests that a psychological intervention, and in particular Acceptance and Commitment Therapy (ACT), may help improve QoL in MD. ACT is a newer type of cognitive behavioural treatment that aims to improve QoL by virtue of improvement in a process called psychological flexibility. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of a guided self-help ACT programme for improving QoL in people with MD. Main secondary outcomes are mood, symptom impact, work and social adjustment and function at 9-week follow-up.

METHODS AND ANALYSIS

Acceptance and Commitment Therapy for Muscle Disease is an assessor-blind, multicentre, two-armed, parallel-group RCT to assess the efficacy of ACT plus standard medical care (SMC) compared with SMC alone. Individuals with a diagnosis of one of four specific MDs, with a duration of at least 6 months and with mild to moderate anxiety or depression (Hospital Anxiety and Depression Scale score ≥8) will be recruited from UK-based MD clinics and MD patient support organisations. Participants will be randomised to either ACT plus SMC or SMC alone by an independent randomisation service. Participants will be followed up at 3, 6 and 9 weeks. Analysis will be intention to treat, conducted by the trial statistician who will be blinded to treatment allocation.

ETHICS AND DISSEMINATION

The study has received full ethical approval. Study results will be disseminated via peer-reviewed publications, conference presentations and journal articles. Data obtained from the trial will enable clinicians and health service providers to make informed decisions regarding the efficacy of ACT for improving QoL for patients with MD.

TRIAL REGISTRATION NUMBER

NCT02810028.

PROTOCOL VERSION

V.11 (4 April 2017).

Genetic Testing of Presymptomatic Individuals at Risk for Progressive Myopathy

Patients and their family members often ask about genetic testing for asymptomatic individuals who are at risk for developing a genetic disorder. Ordering a genetic test is a complex process involving consideration of many basic ethical principles including autonomy, beneficence, and nonmaleficence, as well as the physician's duty to act in the patient's best interest. Physicians have many choices regarding what tests to order, and they must develop the knowledge and skills to best discuss genetic testing with their patients. Integration of core ethical principles into these processes will permit physicians to best serve their patients when obtaining informed consent, considering advantages and harms of potential results, disclosing those results, and providing follow-up.

[Emotions in Motion: Myofascial Interoception]

There are numerous articles in the literature dealing with the myofascial system, on the physiological, pathological, macroscopic and microscopic level; yet, we still do not have a thorough knowledge of its functions, just as there is still no shared vision of how to classify it. Many professional manual practitioners are involved in its treatment and there are many emerging therapeutic approaches. What is still missing is the awareness that the body is also emotion. The myofascial continuum is able to stimulate the areas of the brain that deal with the emotional state, and manual treatment activates the interoceptive system. To optimize myofascial treatment, a psychologist should work alongside the manual practitioner, creating a multidisciplinary team that takes into account both the physical and emotional aspects.

Efficacy of Plai Cream in Adult Patients with Muscle Strain: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Nonsteroidal anti-inflammatory drugs are a standard treatment option for muscle strain; however, side effects persist.

OBJECTIVE

This clinical trial was designed to compare the efficacy of Plai cream compared to placebos in adult patients with muscle strain.

MATERIAL AND METHOD

In this randomized, double-blind, placebo-controlled trial, 140 participants aged over 18 years with muscle strain were randomized to receive either Plai cream (n = 70 patients, treatment group) or placebos (n = 70 patients, control group) . Outcome assessments included the visual analog scale (VAS), quality of life (QoL), the amount of remaining cream, and the number of acetaminophen tablets used.

RESULTS

After 2 weeks, the mean pain scores following treatment with both Plai cream and placebos in patients with muscle strain decreased from baseline to the end of the study at week 2. However, no significant difference for VA S score was found. The QoL of the two groups showed improvements in QoL as witnessed by increased mean QoL scores from baseline to week 2; however, these differences were not statistically significant. In general, mean QoL scores above 50 indicate good quality of life. The amount of Plai cream used reduced from baseline to week 2, but no significant difference in the amount of cream remaining was found between the two groups at each visit. Similarly, the number of acetaminophen tablets used was not statistically different between the treatment and control groups.

CONCLUSION

There was no difference in pain reduction in the 2-week period between patients with muscle strain using Plai cream and those given placebos, but Plai cream tended to reduce pain in the long term. No side effects were found from Plai cream, so this non-invasive treatment may be offered to patients.

The relationships between muscle strength, biomechanical functional moments and health-related quality of life in non-elite older adults

OBJECTIVE

to investigate the association between muscle strength, biomechanical functional moments during everyday tasks and health-related quality of life (HRQoL) in older adults.

METHODS

eighty-four healthy adults aged 60-88 years were tested. A torque dynamometer was utilised to measure muscle moments at the knee and hip joints. Functional assessment involved three-dimensional biomechanical analysis of gait, chair rise and sit-down, stair ascent and descent using an 8-camera VICON® system with Kistler force plates. HRQoL was assessed using the Short Form-36 (SF-36) questionnaire.

RESULTS

Spearman's correlation coefficient showed significant correlation (P < 0.001) between isometric strength and functional moments (r = 0.24-0.67). Muscle strength was significantly correlated with SF-36 scores, including physical functioning, bodily pain, vitality, social functioning and role emotional scores. Knee flexion moment was correlated with role physical, vitality, social functioning, role emotional, mental health and mental component scores (r = 0.24-0.40).

CONCLUSION

loss of muscle strength is associated with poorer functional ability and both are associated with reduced HRQoL. The reduction in HRQoL is considerable in the physical functioning domain. Cause and effect was not established but studies need to be undertaken to evaluate the benefits of strength training, functional activity training or increased participation in life.

Hypnosis as a treatment of chronic widespread pain in general practice: a randomized controlled pilot trial

BACKGROUND

Hypnosis treatment in general practice is a rather new concept. This pilot study was performed to evaluate the effect of a standardized hypnosis treatment used in general practice for patients with chronic widespread pain (CWP).

METHODS

The study was designed as a randomized control group-controlled study. Sixteen patients were randomized into a treatment group or a control group, each constituting eight patients. Seven patients in the treatment group completed the schedule. After the control period, five of the patients in the control group also received treatment, making a total of 12 patients having completed the treatment sessions. The intervention group went through a standardized hypnosis treatment with ten consecutive therapeutic sessions once a week, each lasting for about 30 minutes, focusing on ego-strengthening, relaxation, releasing muscular tension and increasing self-efficacy. A questionnaire was developed in order to calibrate the symptoms before and after the 10 weeks period, and the results were interpolated into a scale from 0 to 100, increasing numbers representing increasing suffering. Data were analyzed by means of T-tests.

RESULTS

The treatment group improved from their symptoms, (change from 62.5 to 55.4), while the control group deteriorated, (change from 37.2 to 45.1), (p = 0,045). The 12 patients who completed the treatment showed a mean improvement from 51.5 to 41.6. (p = 0,046). One year later the corresponding result was 41.3, indicating a persisting improvement.

CONCLUSION

The study indicates that hypnosis treatment may have a positive effect on pain and quality of life for patients with chronic muscular pain. Considering the limited number of patients, more studies should be conducted to confirm the results.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov and released 27.08.07 Reg nr NCT00521807 Approval Number: 05032001.

How children with restricted mobility perceive the accessibility and usability of their home environment

The purpose of this study was to describe how children with restricted mobility perceive accessibility and usability of their home environment. The investigation was carried through a descriptive questionnaire, mailed to children in northern Sweden with the diagnoses of cerebral palsy, spina bifida and muscular diseases. Eighty-two children completed the questionnaire. The results showed that the children perceived the accessibility of the physical environment in their homes as relatively good while outside the home the environment was less accessible. In the social environment, frequency of peer contacts varied. The present study underscores the challenges of ensuring that children with restricted mobility living in the parental home are able to have an accessible and usable environment in order to perform activities. Limitations of this study included the questionnaire design. Further research should be carried out with children with restricted mobility to obtain a better understanding of how to improve their mobility in their home environment.

[Substantiation of psychosomatic nature of temporomandibular joint disorders complicated by parafunctions of masticatory muscles and their combined treatment]

The nature and origin of disorders of masticatory muscles and temporomandibular joint are discussed. Their psychosomatic origin is suggested. Methods of direct and indirect psychotherapy as well as psychopharmacotherapy were included in complex rehabilitation. Computer videoautotraining with biological adaptive feedback was used. 105 patients (31 men and 74 women) at the age of 16-70 years (mean age 34,9+/-1,3 years) were examined. For the first time dysfunction computer arthrophonography of joint sound was used. Combined therapy of this patients was carried out including: psychological correction (suggestion, placebo-therapy, computer videoautotraining), pharmacotherapy (psychotropic, myorelaxative, analgetic drugs preparations), physiotherapy (electrophoresis, phonotherapy, vibroacustic massage), use of orthopaedic apparatuses. Complete recovery or significant improvement of health was observed in 92% of patients, insufficient effect - in 8%.

[How can women with chronic muscular pain change their bodily habits?]

BACKGROUND

Each person develops their own posture and patterns of movement; our bodies are marked by the life we live. Our ways of being imply that the body is used and strained in different ways, and these habits are decisive for what kind of functional problems we may develop. A group-based treatment programme for women with chronic muscular pain includes movement training and group discussions once a week over the course of ten months, aimed at changing straining bodily habits. The study explores what the participants appreciate as meaningful and beneficial effects of this programme.

MATERIAL AND METHODS

A treatment group of ten women with long-lasting chronic muscular pain was organised at the start of the 21st century. Seven of them completed the programme. Transcriptions from individual interviews with the participants were analysed using a phenomenological analysis.

RESULTS

The participants made new bodily experiences, changed their bodily habits and developed strategies for handling stress and pain in daily life.

INTERPRETATION

Group treatment may be a beneficial offer in primary care to women with chronic muscular pain.

The factor validity of the Western Ontario Rotator Cuff Index

Background

The Western Ontario Rotator Cuff Index (WORC) is a self-report questionnaire developed specifically to evaluate disability in persons with pathology of the rotator cuff of the shoulder. The authors created items in 5 categories based on a model of quality of life, but never validated this structure. The purpose of this study was to examine the validity of the original 5-domain model of the WORC by performing factor analysis.

Methods

Three hundred twenty nine subjects (age, mean: 52, SD: 12) were tested prior to undergoing surgery for rotator cuff pathologies. They completed the WORC, a self-report questionnaire, which has 21 items on the effect of the rotator cuff problem on symptoms, activities and emotions. Statistical calculations included correlations between items, Cronbach's alpha of the total scale and subscales, and principal component factor analysis with oblique rotation.

Results

Correlations ranged from .09 to .70 between all the items, from .29 to .70 between items within a subscale, and from .53 to .72 between subscale scores. Cronbach's alpha was .93 for the total scale, and .72 to .82 for the subscales. The factor analysis produced 3 factors that explained 57% of the variance. The first factor included symptoms and emotional items, the second included strength items and the third included daily activities.

Conclusion

The results of this study did not support the 5-domain model of the WORC.

Segmental inhibition of cutaneous heat sensation and of laser-evoked potentials by experimental muscle pain

The aim of the study was to evaluate the effect of tonic muscle pain evoked by injection of 5% hypertonic saline in the right brachioradialis muscle on the somatosensory sensation of laser-evoked heat pain and laser-evoked potentials. The heat pain pathways were studied in 9 healthy human subjects by recording the scalp potentials evoked by CO(2) laser stimuli delivered on four sites: the skin above the right brachioradialis muscle (ipsilateral local pain), the wrist area where muscle pain was referred in all subjects (ipsilateral referred pain), and two areas on the left arm symmetrical to both local and referred pain (contralateral local pain and contralateral referred pain). Laser-evoked potentials were obtained from 31 scalp electrodes before saline injection, during saline infusion (bolus injection with 0.3 ml saline infused over 20 s, followed by a steady infusion rate of 30 ml/h for the next 25 min), and 20 min after muscle pain had disappeared. While the early N1/P1 component (around 130 ms and 145 ms of latency after stimulation of the skin over the brachioradialis muscle and the wrist, respectively) was not affected by muscle pain, the amplitudes of the later vertex laser-evoked potentials (N2 latency of around 175 ms and 210 ms after stimulation of the skin over the brachioradialis muscle and the wrist, respectively; P2 latency of around 305 ms and 335 ms after stimulation of the skin over the brachioradialis muscle and the wrist, respectively) evoked from ipsilateral local pain, ipsilateral referred pain, and contralateral local pain sites were significantly decreased during muscle pain compared with the baseline recording, while they recovered after pain had disappeared. At the same stimulation sites, the rating of the laser-evoked pain sensation was reduced significantly during muscle pain as compared with the baseline and it recovered after pain had disappeared. On the contrary, muscle pain did not show any effect on both laser-evoked pain and laser-evoked potential amplitude when the contralateral referred pain site was stimulated. The muscle pain inhibitory effect on both heat pain sensation and laser-evoked potential amplitude is probably mediated by an ipsilateral and contralateral segmental mechanism which acts also on the referred pain area, while more general inhibitory mechanisms, such as a distraction effect or a diffuse noxious inhibitory control, are excluded by the absence of any effect of muscle pain on laser-evoked pain and laser-evoked potentials obtained from a remote site, such as the contralateral referred pain area. Since muscle pain induced by hypertonic saline injection is very similar to clinical pain, our results can be useful in understanding the pathophysiology of the somatosensory modifications which can be observed in patients with musculoskeletal pain syndromes.

"I am allowed to be myself": women with chronic muscular pain being recognized

AIMS

Since 1992, the authors have completed 11 treatment groups for women with chronic muscular pain. The programme includes movement training and group discussions. Qualitative data indicate that the participants valued the experience of being recognized in the groups as a crucial and beneficial effect of the treatment. In the present article, this finding is examined in more detail by studying the types of action and interaction that the women considered to have benefited from by participating in group treatment.

METHODS

Data are drawn from an action research project and the material originates from three treatment groups where 24 participants completed the programme. Qualitative data originating from five focus group interviews are analysed using Giorgi's principles of phenomenological analysis.

RESULTS

The women described different concrete aspects of interaction and awareness illustrating psychologist Løvlie Schibbye's theoretical perspectives of a recognizing attitude: listening, understanding, acceptance, tolerance, and confirmation. The women tell how they themselves have experienced these expressions of recognition from other group members and from the group leaders.

CONCLUSIONS

The women confirmed that recognition had an important effect on how much they benefited from the treatment programme. The need for mutual recognition draws attention to the power and possible abuse of power inherent in human relationships, as exemplified by the relationship between the patient and healthcare providers. An explicit presentation of the human and moral value behind the treatment programme represents a challenge.

Exploring perceived tension as a response to psychosocial work stress

This study extends the concept of tension, in part by observing changes in tension during the workday, to identify episodes causing elevated tension and relate them to bodily responses. Methods Both questionnaires and qualitative interviews were used to describe the tension concept. Tension was scored on a visual analogue scale (VAS) every hour, and trapezius muscle activity and heart rate were recorded. Ninety-four female workers from four service occupations participated.

RESULTS

Tension was described as a musculoskeletal activation response involving the upper body regions, but also autonomic activation responses were described. The cause of elevated tension comprised a variety of situational demands; however, contact with other people causing negative emotions was a common factor. Averaged muscular activity and heart rate responses did not correlate with prolonged perceived tension, but the differential tension score between high- and low-tension periods correlated with the corresponding differential trapezius activity responses. The regression line indicated no effect of short-term variation in perceived tension on median muscle activity for differential VAS scores of < or = 2 cm. An increase of 2% of maximal electromyographic activity for a differential VAS score of 4-5 cm was indicated.

CONCLUSIONS

This study identifies work exposures that cause tension, and it demonstrates a physiological correlate with the subjective perception of tension in the short term. The low recorded muscle activationresponse does not represent a risk factor for pain by the traditional standards used for recording and evaluating muscle activity responses, but it may point to underlying pain-inducing mechanisms, such as low-threshold overexertion of motor units.

Opposite effects of ethanol and ketamine in the elevated plus-maze test in Wistar rats undergoing a chronic oral voluntary consumption procedure

The anxiolytic effects of ethanol (EtOH) have been involved in the vulnerability to EtOH drinking in humans. However, the role of the anxiolytic effects of EtOH during a chronic ingestion of the drug has not been extensively addressed, either in humans or in animal models. Since it was first shown that EtOH interacts with the N-methyl-d-aspartate (NMDA) receptor, a growing body of evidence demonstrating the involvement of this receptor in a wide range of EtOH effects has been reported. The present study aimed to investigate the ability of a voluntary consumption of EtOH to exert its putative anxiolytic-like activity in non-selected male Wistar rats held under a voluntary chronic oral consumption procedure using the elevated plus-maze (EPM) test. The effects of EtOH were compared with those of the noncompetitive NMDA receptor antagonist ketamine (KET), and with a mixture of both drugs. Rats were provided with 1-h limited access to one of the following sweetened (10% w/v glucose) solutions: (i) control; (ii) EtOH (ethanol, 10% v/v); (iii) KET (ketamine HCl, 0.28 mg/ml); or (iv) mixed (EtOH 10% v/v plus ketamine HCl 0.28 mg/ml) for 35 consecutive days. At the end of this period, and immediately after the last 1-h access to the respective solution, animals were independently tested in either EPM or open field tests. Previously, rats were tested on the inclined screen test during 15 consecutive days. The opposite effects were observed with EtOH and KET consumption in the EPM test, with EtOH decreasing and KET increasing the percentage of time spent in the open arms of the EPM, which was shown to be independent of any locomotor impairment, whereas consumption of the mixed solution did not significantly affect any test. Since the EtOH did not exhibit anxiolytic-like effects after its chronic oral consumption, it might be hypothesized that the anxiolytic activity of the EtOH is not critically involved in the maintenance of a voluntary EtOH consumption in non-selected rats. On the other hand, the lack of effects from mixed solution consumption suggests that EtOH and KET may interact in such a way that their effects are neutralized.

[The role of suprasegmental and segmental autonomic disorders in the development of muscular syndrome of rheumatoid arthritis]

AID: To investigate the role of suprasegmental (anxious disorders) and segmental vegetative disorders (dysfunction of neuromuscular transmission and cutaneous microcirculation) in pathogenesis of muscular syndrome of rheumatoid arthritis (RA).

MATERIAL AND METHODS

MMPI, Beck's questionnaire, Spilberger's test were used in experimental-psychological assessment of RA patients' personality profile. A total of 60 healthy subjects and 340 RA patients were examined. Segmental vegetative disorders were studied by excitability of hand muscles (Prognoz-6 device) and cutaneous microcirculation (doppler flowmetry).

RESULTS

RA patients showed suprasegmental disorders manifesting as frequent anxious disturbances (95%). Dysfunction of the segmental part of the autonomic nervous system was represented by various changes in excitability of hand muscles in response to weak currents, by abnormal regulation of cutaneous microcirculation.

CONCLUSION

Neuromuscular and microcirculation disturbances participate in development of RA muscular syndrome. This is confirmed by a positive correlation coefficient. There was also a negative correlation between suprasegmental and segmental disorders.

Self-reported symptoms among Danish women following cosmetic breast implant surgery

The aim of this study was to examine self-reported symptomatology and to identify distinctive characteristics among women with silicone breast implants (SBI). Using the Danish hospital and population registers we identified three groups of women with a hospital diagnosis of muscular rheumatism (a nonspecific soft-tissue diagnostic code) who had previously undergone SBI surgery (n = 28), breast reduction surgery (n = 29) or no breast surgery (n = 27); and three groups of women without a diagnosis of muscular rheumatism who had undergone SBI surgery (n = 21), breast reduction surgery (n = 27) or no breast surgery (n = 56). All study subjects completed a self-administered questionnaire focusing on sociodemographic factors, lifestyle habits, somatic symptoms and psychological symptoms. Women with SBI and women with breast reduction with no previous diagnosis of muscular rheumatism had similar patterns of reporting for most symptoms and characteristics. They reported significantly more somatic symptoms and psychological distress, including somatisation, obsessive-compulsiveness and depression, than women with no breast surgery. No significant differences in self-reported symptomatology and characteristics were observed among the three groups of women with a previous diagnosis of muscular rheumatism. Overall, women with prior muscular rheumatism reported more symptoms than those without. We concluded that self-reported somatic symptoms among women with SBI were similar to those of controls. Women with cosmetic breast surgery appear to have distinctive psychological characteristics. Our study emphasises the importance of taking the psychological profile and previous history of rheumatic diseases into account when examining women with SBI.

Preliminary evidence for a cognitive phenotype in Barth syndrome

Barth syndrome (BTHS) is a rare, X-linked, recessive disorder that affects almost exclusively males. It is characterized by short stature, cardioskeletal myopathy, cyclic neutropenia, increased excretion of 3-methylglutaconic acid in the urine, and moderate hypocholesterolemia. The objective of the present study was to assess whether BTHS presents with a cognitive phenotype. Preliminary data were collected from five kindergarten or first-grade boys with BTHS. An abbreviated psychoeducational test battery was administered to each boy, and parents of each boy completed standardized behavior rating scales. Data from 120 boys of similar age or grade level were used for one comparison group; a subset of this sample comprised a comparison group that was individually matched on age and grade level to one of the five boys with BTHS. Preliminary data reflect a higher incidence of cognitive difficulties in boys with BTHS relative to both comparison groups. Boys with BTHS had significantly lower visual spatial skills, but comparable reading-related skills, when compared with either group. Although based on a small sample size, the preliminary data presented in this work are the first indication of a cognitive phenotype associated with BTHS.

Psychological distress in chronic craniomandibular and cervical spinal pain patients

Recent studies to chronic pain have shown that the number of painful body areas is related to the level of psychological distress. Therefore, the first aim of this study was to analyse differences in level of psychological distress between craniomandibular pain patients with or without cervical spinal pain. In this analysis, the number of painful body areas below the cervical spine was also taken into account. The second aim was to determine psychological differences between subgroups of craniomandibular pain patients. In this study, 103 out of 250 persons with or without craniomandibular pain were included in the final analyses. Patients who suffered from both craniomandibular and cervical spinal pain showed higher levels of psychological distress, as measured with the Symptom Checklist 90 (SCL-90) than patients with local craniomandibular pain and persons without pain. Further, a positive relationship was found between the number of painful body areas below the cervical spine, as measured on a body drawing, and the SCL-90 scores. No psychological differences were found between myogenous and arthrogenous craniomandibular pain patients. In conclusion, chronic craniomandibular pain patients with a coexistent cervical spinal pain showed more psychological distress compared to patients with only a local craniomandibular pain and asymptomatic persons.

Ketamine reduces muscle pain, temporal summation, and referred pain in fibromyalgia patients

Central mechanisms related to referred muscle pain and temporal summation of muscular nociceptive activity are facilitated in fibromyalgia syndrome (FMS) patients. The present study assessed the effects of an NMDA-antagonist (ketamine) on these central mechanisms. FMS patients received either i.v. placebo or ketamine (0.3 mg/kg, Ketalar((R))50% decrease in pain intensity at rest by active drug on two consecutive VAS assessments). Fifteen out of 17 ketamine-responders were included in the second part of the study. Before and after ketamine or placebo, experimental local and referred pain was induced by intramuscular (i.m.) infusion of hypertonic saline (0.7 ml, 5%) into the tibialis anterior (TA) muscle. The saline-induced pain intensity was assessed on an electronic VAS, and the distribution of pain drawn by the subject. In addition, the pain threshold (PT) to i.m. electrical stimulation was determined for single stimulus and five repeated (2 Hz, temporal summation) stimuli. The pressure PT of the TA muscle was determined, and the pressure PT and pressure pain tolerance threshold were determined at three bilaterally located tenderpoints (knee, epicondyle, and mid upper trapezius). VAS scores of pain at rest were progressively reduced during ketamine infusion compared with placebo infusion. Pain intensity (area under the VAS curve) to the post-drug infusion of hypertonic saline was reduced by ketamine (-18. 4+/-0.3% of pre-drug VAS area) compared with placebo (29.9+/-18.8%, P<0.02). Local and referred pain areas were reduced by ketamine (-12. 0+/-14.6% of pre-drug pain areas) compared with placebo (126.3+/-83. 2%, P<0.03). Ketamine had no significant effect on the PT to single i.m. electrical stimulation. However, the span between the PT to single and repeated i.m. stimuli was significantly decreased by the ketamine (-42.3+/-15.0% of pre-drug PT) compared with placebo (50. 5+/-49.2%, P<0.03) indicating a predominant effect on temporal summation. Mean pressure pain tolerance from the three paired tenderpoints was increased by ketamine (16.6+/-6.2% of pre-drug thresholds) compared with placebo (-2.3+/-4.9%, P<0.009). The pressure PT at the TA muscle was increased after ketamine (42.4+/-9. 2% of pre-drug PT) compared with placebo (7.0+/-6.6%, P<0.011). The present study showed that mechanisms involved in referred pain, temporal summation, muscular hyperalgesia, and muscle pain at rest were attenuated by the NMDA-antagonist in FMS patients. It suggested a link between central hyperexcitability and the mechanisms for facilitated referred pain and temporal summation in a sub-group of the fibromyalgia syndrome patients. Whether this is specific for FMS patients or a general phenomena in painful musculoskeletal disorders is not known.

A new animal model for assessing mechanisms and management of muscle hyperalgesia

Musculoskeletal pain is one of the most frequent symptoms for which medical assistance is sought. Yet, the majority of our knowledge regarding pain physiology is based on studies of cutaneous tissue. Comparatively little is known about activation of visceral, joint and perhaps least of all, musculoskeletal nociceptors although clinically-treated pain originates principally in these structures. Studies elucidating the mechanisms of muscle hyperalgesia have been hampered by the lack of an animal model that permits the evaluation of hypotheses using behavioral, biochemical, pharmacological, anatomical and molecular experimental approaches. Here we describe an animal model of muscle hyperalgesia we recently developed that permits such multidisciplinary investigation. This model employs the intramuscular injection of carrageenan, a chemical stimulus which evokes a well recognized model of cutaneous inflammation and is reported to activate muscle nociceptors. Intramuscular carrageenan evokes a time- and dose-dependent reduction in forelimb grip force that is anatomically specific. The carrageenan-evoked reduction in grip force is blocked by the mu-opioid agonist levorphanol in a dose-dependent, stereoselective and naltrexone-reversible manner. This behavioral dependent measure is also significantly reversed by agents used clinically to treat muscle pain, indomethacin and dexamethasone, as well as the non-competitive N-methyl-D-aspartate receptor antagonist MK801. Finally, evidence that reduction in grip force is in part mediated by small, unmyelinated afferents is provided by the demonstration that neonatal capsaicin treatment significantly reduced carrageenan-evoked behavioral hyperalgesia ( approximately 45% reduction) and reduced muscle content of immunoreactive CGRP ( approximately 60% reduction) relative to control levels. Collectively, these findings provide converging lines of evidence for the validity of this animal model to investigate mechanisms involved in the development of muscle hyperalgesia.

Effects of physical and mental stressors on muscle pain

Physical and mental stressors as risk factors for pain development are discussed. These multifaceted stressor terms are narrowed down so that physical stressors are represented by muscle activity recorded by electromyography (EMG), while mental stress is considered synonymous with psychosocial stress in vocational studies; in experimental studies cognitive stress is used as a model. Pain in the shoulder and neck are focused and related to EMG recordings of activity in the trapezius muscle. Major challenges in this field include proper risk assessment at low physical work loads and criteria for evaluating stress as a risk factor. A 3-factor conceptual model is presented in which the independent dimensions physical work load, mental stress, and individual sensitivity determine the risk of shoulder and neck complaints. It is pointed out that a predominant reduction in physical work load for many jobs and an increasing interaction between work conditions and the general life situation of workers pose particular challenges for risk assessment.

Quantification of local and referred muscle pain in humans after sequential i.m. injections of hypertonic saline

The aim of the present study was to test (1) whether muscle pain is influenced by temporal and spatial summation, and (2) whether sequential noxious muscle stimuli applied at hourly interstimulus-intervals could produce an increased sensation of pain due to central hyperexcitability. In the study eleven healthy men were exposed to computer-controlled intramuscular infusion of saline (5%) given over 20 s in m. tibialis anterior (m. TA). The intensities of local and referred pain were assessed by recordings on visual analogue scales (VAS), and the areas of local pain (around the injection site) and referred pain (outside the local pain area) were localised by the subject. Three experiments were performed. Experiment 1: Each subject participated in three tests separated by one week: (a) bolus (0.4 ml saline) infusion at one site; (b) four sequential infusions (0.1 ml saline) given at 90-s interstimulus-intervals at one site; and (c) four sequential infusions (0.1 ml saline) given at 360-s interstimulus-intervals at one site. Experiment 2: This was performed as experiment 1, but the infusions were given at spatially separated sites. Experiment 3. Hypertonic saline (0.1 ml) was injected one, four and 24 h after the sequential infusions (90-s interstimulus-intervals) given at spatially separated sites. The highest VAS peak and the largest local and referred pain areas were found after the bolus infusions. Compared to the first infusion, significant increases were found in the VAS peak, the size of the local pain area, and the size of the referred pain area (non-significant) after the four sequential infusions given at 90-s interstimulus-intervals (temporal summation). Four spatially separated infusions given simultaneously produced a higher VAS peak, a larger local pain area, and a larger referred pain area (non-significant) compared to one infusion (spatial summation). The infusion given 4 h after the sequential infusions tended to produce an increase in the referred pain area and in the pain intensity. In all three experiments significant correlations were found between the VAS peak and the size of the local (R = 0.64, P < 0.0001, n = 231) and referred (R = 0.47, P < 0.0001, n = 231) pain areas. Based on the above results it can be concluded that experimental muscle pain is influenced by temporal and spatial summation.

[Mobility and group discussions. Treatment of chronic muscle pain in women in general practice]

We describe the development of a programme based on group treatment for women suffering from chronic muscle pain, and the experience gained from it. Six such groups underwent 12 weeks of treatment consisting of specially adapted physical training twice weekly and a weekly discussion group in which a general practitioner and a physiotherapist took part. 60 of the 80 women who started the programme completed it. This assessment is based on in-training observations, interviews and a questionnaire. The participants maintain that they found the combination of physical and relaxation exercises, and the discussions, the social aspect and the mutual exchange of knowledge, beneficial. Their physical ability improved, they got more enjoyment from movement and achieved a greater sense of well-being. The extent of benefit experienced by the individual participant was dependent upon her feelings respected and appreciated, her sense of achievement and her ability to understand how various personal factors are related. The women underlined the benefit of a training programme based on mobility rather than stamina, and including discussion groups characterized by acceptance, a sense of belonging and co-operation. We believe that this approach can be further developed at general practitioner level, provided that the individual participant meets recognition and acceptance of her experiences, her feelings connected with physical activity and her background.

Myopathic involvement in two cases of Hallervorden-Spatz disease

Muscle biopsy was performed in two patients with Hallervorden-Spatz disease and increased serum creatine kinase levels. Morphological analysis showed myopathic signs such as subsarcolemmal accumulation of myeloid structures, dense bodies and debris, endomysial macrophage activation, focal necrosis and fiber splitting. We emphasize the finding of muscle involvement in Hallervorden-Spatz disease, like in other forms of neuroacanthocytosis.

The use of topical 4% lidocaine in spheno-palatine ganglion blocks for the treatment of chronic muscle pain syndromes: a randomized, controlled trial

To assess the efficacy of 4% topical lidocaine in spheno-palatine blocks, a randomized controlled trial was carried out on patients with chronic muscle pain syndromes. Sixty-one patients (42 with fibromyalgia (FM) and 19 with myofascial pain syndrome (MPS)) completed the trial. Outcome measures included pain intensity, a daily pain diary, headache frequency, sensitivity to pressure using a dolorimeter, anxiety, depression, and sleep quality. Patients were randomized to receive either 4% lidocaine or sterile water (placebo) 6 times over a 3-week period. Both subjects and investigators were blind to treatment allocation. The results showed that 4% lidocaine had no superiority over placebo in any of the outcome measures. Twenty-one subjects (35%) showed a decrease in pain which was greater than 30% of their baseline value. Of these 21 subjects, 10 received lidocaine and 11 received placebo. These data suggest that, in this population, 4% lidocaine is no better than placebo in the treatment of chronic muscle pain.

Rectus syndrome. Another cause of upper abdominal pain

BACKGROUND AND OBJECTIVES

Rectus syndrome is somatic pain originating from the rectus abdominis musculature of the abdomen. However, pain with its associated somatovisceral symptoms such as nausea, vomiting, and anorexia, is called pseudovisceral pain syndrome. It commonly mimics abdominal visceral pain and misleads medical practitioners into establishing a wrong diagnosis and giving inadequate pain management. Owing to its primary somatic origin, a regional rectus nerve block is an efficacious modality for use in differentiating the diagnosis and providing longlasting optimal pain relief.

METHODS

Two cases, a 48-year-old man and a 41-year-old woman, were referred for the management of chronic upper abdominal pain consistent with chronic pancreatitis. They underwent rectus block, first to differentiate the diagnosis and then to relieve intractable pain problems with multidisciplinary pain management.

RESULTS

Rectus block was performed successfully, and a diagnosis of rectus syndrome was established. These two patients responded to the rectus block immediately and received long-lasting pain relief after repeated rectus blocks in conjunction with pharmacologic and psychological treatment and physiotherapy.

CONCLUSION

Rectus syndrome could be another potential cause of chronic intractable upper abdominal pain problem; rectus block provides a simple diagnostic and therapeutic technique to differentiate the diagnosis and treat it adequately.

Impact of regular relaxation training and psychosocial working factors on neck-shoulder tension and absenteeism in hospital cleaners

Occupational stress in hospital cleaners (n = 50), and the effect of relaxation training (n = 25, age matched, randomized), were studied by recording the electrical activity of the upper trapezius muscle at rest and during working conditions at the beginning, middle, and end of a 6-month follow-up period. A short (15-minute) relaxation program was practiced daily at the workplace to provide stress management. The amount of sick leave was counted, and the extent of depression and some psychosocial working factors were screened. Intercorrelations were found between the neck-shoulder tension, psychosocial factors, depression, and the absentee rate. The relaxation training diminished tension in the neck-shoulder region efficiently; nevertheless, the decrease in absenteeism might have been related mainly to the social support offered by the research maneuver itself.

Muscle endurance, muscle tension and personality traits in patients with muscle or joint pain--a pilot study

OBJECTIVE

To investigate the relationships between personality traits, depressive symptomatology and continuous muscle tension.

METHODS

These were investigated by means of a visual analog scale and the presence of continuous muscle tension during repeated isokinetic shoulder flexions in patients with muscle or joint pain and controls.

RESULTS

A significantly higher level of muscle tension between contractions was found in the patient groups in painful muscles. The patients with primary fibromyalgia and trapezius myalgia differed in degree of depressive symptomatology compared to controls.

CONCLUSION

Inhibition of aggression correlated significantly with the tension level between contractions during the isokinetic test indicating interaction between psychological and somatic factors.

Joint impairment and self-reported disability in elderly persons

Recent findings indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. We conducted physical examinations of the joints at baseline on 541 older persons. We then tested a multivariate model of total/generic disability which included respondent group, demographic and chronic disease variables (joint impairment and comorbid conditions), arthritis pain, and psychological status. Hierarchical multiple regression found that the model explained 55 percent (adjusted R2 = .55) of the variance in baseline disability with joint impairment accounting for 15 percent (change in R2 = .15) of the variance. When joint impairment was removed from the model, arthritis pain worked well as a surrogate. Together, these findings strongly support the importance of musculoskeletal disease in explaining disability in the elderly population.

Low back and neck/shoulder pain in construction workers: occupational workload and psychosocial risk factors. Part 1: Relationship to low back pain

The prevalence rate of musculoskeletal problems, especially low back pain and severe low back pain in a randomly selected sample of 1,773 construction workers was studied. Its relationship to physical and psychosocial factors was analyzed. The workers answered a postal questionnaire. Workload was measured by means of eight manual materials handling indices and ten psychosocial indices, based on results from factor analyses. The 1-year prevalence rate of low back pain was 54% and of severe low back pain 7%. The relationship to heavy manual materials handling differed with age in such a manner that it could be interpreted as a healthy worker effect. Between severe low back pain and both stooping or kneeling a dose-response relationship was found. The most prominent of the psychosocial factors associated with low back pain and severe low back pain were the stress index and the psychosomatic and psychic indices. The age-standardized prevalence rate ratio of low back pain was 1.6 (95% confidence interval 1.4-1.8) and for severe low back pain 3.1 (95% confidence interval 2.3-4), when workers reporting "high" stress were compared to workers reporting "low" stress.

Low back and neck/shoulder pain in construction workers: occupational workload and psychosocial risk factors. Part 2: Relationship to neck and shoulder pain

The prevalence rate of neck and shoulder trouble and considerable neck and shoulder pain in a randomly selected sample of 1773 construction workers were studied. The relationship to physical and psychosocial factors was analyzed. The workers answered a postal questionnaire. Workload was measured by means of eight manual materials handling indices and ten psychosocial indices, based on results from factor analyses. The 1-year prevalence rate of considerable neck and shoulder trouble was 56% and of neck and shoulder pain 12%. To work with hands above shoulder level showed a dose-response relationship to both neck and shoulder trouble and neck and shoulder pain. The psychosocial factors were more prominently associated with neck and shoulder trouble and neck and shoulder pain than the physical workload factors. The psychosocial indices; psychosomatic and psychic symptoms, stress and job satisfaction showed the highest age-standardized prevalence rate ratios for both neck and shoulder trouble and neck and shoulder pain.

Early detection measures and triage procedures for suicide ideation in chronic pain patients

There is a dearth of writings about early detection of potential suicide patients in chronic pain centers. Early detection measures used at the Vanderbilt Pain Control Center include a Symptom Checklist-90, with questions about depressive symptomatology and "Thoughts of Ending Your Life"; medical and psychological interviews; monitoring of changes in emotional disturbance; and, if warranted, administration of the Scale of Suicidal Ideation. Three case studies are presented that indicate that the results of an assessment measure should be tempered with clinical judgment. Suicidal behavior, including suicidal ideation, is a medical emergency; therefore, there is great need for early detection and triage measures.

The neuropsychological features of mitochondrial myopathies and encephalomyopathies

Detailed testing of higher cerebral function was performed in 36 patients with mitochondrial myopathies and encephalomyopathies. Fourteen of these patients were thought to be cognitively impaired on clinical grounds. The assessments included tests of general intellectual ability and focal tests of memory, language, and perception. Twenty-one (58%) of the 36 patients who were tested had evidence of general intellectual deterioration, with focal cognitive deficits of variable degree. Of the remaining 15 patients in whom there was no evidence of general intellectual decline, five displayed focal cognitive deficits. In only 10 patients was there evidence of cerebral dysfunction. The range and extent of cognitive deficits in mitochondrial myopathies are greater than predicted by their clinical presentations.

A comparative psychiatric assessment of patients with chronic fatigue syndrome and muscle disease

The psychiatric status of patients with chronic fatigue syndrome (N = 34) and muscle disease (N = 24) attending a general medical clinic was studied. Among fatigue patients 14 (41.2%) were cases and a further 9 (26.5%) were subcases of psychiatric disorder as defined by CATEGO. A variety of diagnoses was found. Significantly fewer of the muscle patients had a psychiatric disorder with 3 (12.5%) being cases and 1 (4%) a subcase. The relative risk of psychiatric disorder in patients with chronic fatigue syndrome compared to patients with muscle disease was 3.3:1.

[Psychomotor physical therapy--patients' starting point and their evaluation of the therapeutic results]

Psychomotor physiotherapy is a technique which aims, through relief of muscular tension and inhibited breathing, to give the patient a better understanding of the connection between mental and somatic reactions, establish improved coping patterns. In a three-year, prospective registration of 152 patients referred to psychomotor physiotherapy the expectations of the patients were evaluated, along with the presented symptoms. After 6-12 months of treatment 75% experienced a relief of symptoms, and 50% a change in symptom profile. At follow-up of 109 patients after 2 1/2 years we found a significant improvement in symptoms as well as in parameters for everyday coping, and a marked reduction in use of drugs. There was a correlation between an academic education and response to treatment.

Cognitive impairment in musculoskeletal pain patients

To assess the incidence and relationship of cognitive/intellectual impairments to pain problems, seventy-three adults with musculoskeletal pain seen in a PM&R outpatient clinic were screened using the Neurobehavioral Cognitive Status Examination (NCSE). Subjective pain complaints were assessed using portions of the McGill Pain Questionnaire. Patients with prior diagnoses of neurocognitive problems or those who had taken narcotic analgesics in the last 24 hours were excluded. Results showed that 32 percent of subjects had impaired performance in at least one cognitive domain. Individuals with poorer performance on the NCSE had higher levels of reported pain or disability and psychological distress. Possible factors contributing to poor performance on cognitive tasks include psychological disorders or distress, undiagnosed organic brain dysfunction, social/psychological factors such as education, or a combination of these. Results suggest the need for further research to understand the relationship of poor performance on cognitive tasks to the etiology, maintenance and rehabilitation of pain problems.

Tenderness and pain in neck and shoulders in relation to Type A behaviour

158 males employees in the metal industry, aged 35-44 years, were examined to determine the prevalence of tenderness and pain in the neck and shoulders. Type A behaviour was assessed by a series of 16 questions. One or more tender sites were found in 30% and more than three in 7% of the examined employees. Tenderness was twice as common among those with interview-based pain in the past 12 months (40%) as among those without pain (23%). Those with tenderness on palpation more often had a type A behaviour than those without tenderness (p = 0.010). The association was modified by pain but not by occupation. One explanation for the association between tenderness and behaviour might be that type A personality is associated with increased muscle activity in the neck and shoulders leading to muscular fatigue and tenderness.