Myofascial component of cancer pain review

BackgroundPain 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.Aims1) To estimate the prevalence of MPS in cancer patients; 2) to examine the efficacy of current treatment options for MPS in cancer patients.MethodsNarrative 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.ResultsMPS 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.ConclusionsWe 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.     

Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache

Background

Tension-type headache (TTH) is essentially defined as bilateral headache of a pressing or tightening quality without a known medical cause. Myofascial release (MFR) is currently being applied for patients with TTH but its efficacy has not been evaluated formally.

Objective

To investigate whether direct technique myofascial release (DT-MFR) reduces the frequency of headache more effectively than the indirect technique myofascial release (IDT-MFR) in comparison to a Control Group receiving slow soft stroking.

Design

Randomized, controlled, single blinded trial.

Setting

The clinical wing of Myofascial Therapy and Research Foundation, Kerala, India.

Participants

63 patients with episodic or chronic tension-type headache.

Interventions

DT-MFR, IDT-MFR or Control. The techniques were administered by certified myofascial release practitioners and consisted of 24 sessions per patient over 12 weeks.

Main outcome measure

Difference in numbers of days with headache between Weeks 1–4 (i.e. 4 weeks prior to start of Intervention) and Weeks 17–20, following 12 weeks of Intervention between Weeks 5–16 as recorded by participants in headache diaries.

Results

The number of days with headache per 4 weeks decreased by 7.1 (2.6) [mean (SD)] days in the DT-MFR group compared with 6.7 (1.8) days in the IDT-MFR group and 1.6 (0.5) days in the control group, (P < 0.001). Patients in the DT-MFR Group, IDT-MFR Group and Control Group reported a 59.2%, 54% and 13.3% reduction in their headache frequency in Weeks 17–20 compared to that in Weeks 1–4.

Conclusions

This study provides evidence that Direct Technique or Indirect Technique Myofascial Release is more effective than the Control Intervention for tension headache.     

Role of fascial connectivity in musculoskeletal dysfunctions: A narrative review

IntroductionMusculoskeletal dysfunctions happen to be the most common reason for referral to physiotherapy and manual therapy services. Therapists use several articular and/or soft tissue concepts/approaches to evaluate and treat such dysfunctions that may include integration of myofascial system. Despite the research in this area spanning more than three decades, the role played by fascia has not received its duly deserved attention, owing to the lack of definitive research evidence. The concept of ‘fascial connectivity’ evolved two decades ago from a simple anatomical hypothesis called ‘myofascial meridians’. Since then it has been widely researched, as conceptually it makes more sense for functional movements than ‘single-muscle’ theory. Researchers have been exploring its existence and role in musculoskeletal dysfunctions and clinicians continue to practice based on anecdotal evidence. This narrative review attempts to gather available evidence, in order to support and facilitate further research that can enhance evidence based practice in this field.MethodsA search of most major databases was conducted with relevant keywords that yielded 272 articles as of December 2019. Thirty five articles were included for final review with level of evidence ranging from 3b to 2a (as per Center of Evidence Based Medicine's scoring).ResultsFindings from cadaveric, animal and human studies supports the claim of fascial connectivity to neighboring structures in the course of specific muscle-fascia chains that may have significant clinical implications. Current research (level 2) supports the existence of certain myofascial connections and their potential role in the manifestation of musculoskeletal dysfunctions and their treatment.ConclusionAlthough these reviews and trials yield positive evidence for the objective reality/existence of fascial connectivity and continuity, several aspects need further exploration and in-depth analysis, which could not be evidenced entirely in this review. Manual and physical therapists may utilize the concept of fascial connectivity as a convincing justification to deal with clinical problems, but need to remain vigilant that functional implications are still being investigated.     

Abstract 17: A novel microanalytical technique for assaying soft tissue demonstrates significant quantitative biochemical differences in 3 clinically distinct groups: normal, latent, and active.

Objectives: To determine (1) whether a novel microdialysis needle can successfully sample the biochemical milieu of trigger point 1 (TP1) in the upper trapezius muscle in healthy subjects and (2) whether there are measurable differences among those with symptoms and physical findings related to myofascial trigger points (MTrPs). Design: Prospective, controlled trial. Setting: Biomedical research hospital. Participants: 3 subjects were selected based on history and physical examination for 3 groups (N=9): group 1, normal (no neck pain, no MTrP); group 2, latent (no neck pain, MTrP present); and group 3, active (neck pain, MTrP present). Intervention: Pressure algometry was performed at TP1 to determine pain pressure threshold (PPT). Samples were obtained continuously with a microdialysis needle at regular intervals, starting with needle insertion, elicitation of a local twitch response, and then posttwitch. Main Outcome Measures: PPT and levels of pH, substance P, calcitonin gene-related peptide (CGRP), bradykinin, norepinephrine, tumor necrosis factor-alpha (TNF_α), and interleukin-1β (IL-1β). Results: The active group had a lower PPT (P<.08). Overall, the amount of substance P, CGRP, bradykinin, norepinephrine, TNF_α, and IL-1β was significantly higher in the active group than in the other 2 groups (P<.01). Overall, pH was significantly lower in the active group than in the other 2 groups (P<.03). At 5 minutes, peak levels of substance P and CGRP differed significantly in all 3 groups (3>2>1, P<.02). Conclusions: This technique recovered extremely small quantities (<0.5μL) of very small substances (molecular weight, <100kd) directly from soft tissue. There were significant differences in the levels of pH, substance P, CGRP, bradykinin, norepinephrine, TNF_α, and IL-1β in those subjects with an active MTrP (symptoms, MTrP present) compared with subjects with a latent MTrP (no symptoms, MTrP present) and normal subjects (no symptoms, no MTrP).     

Dry needling in the management of myofascial trigger points: A systematic review of randomized controlled trials

ObjectiveThis systematic review of randomized controlled trials aimed to examine the effectiveness of dry needling in the treatment of myofascial trigger points and to explore the impact of specific aspects of the technique on its effectiveness.MethodsRelevant studies published between 2000 and 2015 were identified by searching PubMed, Scopus, The Cochrane Library and Physiotherapy Evidence Database. Studies identified by electronic searches were screened against a set of pre-defined inclusion criteria.ResultsFifteen studies were included in this systematic review. The main outcomes that were measured were pain, range of motion, disability, depression and quality of life. The results suggest that dry needling is effective in the short term for pain relief, increase range of motion and improve quality of life when compared to no intervention/sham/placebo. There is insufficient evidence on its effect on disability, analgesic medication intake and sleep quality.ConclusionsDespite some evidence for a positive effect in the short term, further randomized clinical trials of high methodological quality, using standardized procedures for the application of dry needling are needed.     

Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome

This article discusses muscle pain concepts in the context of myofascial pain syndrome (MPS) and summarizes microdialysis studies that have surveyed the biochemical basis of this musculoskeletal pain condition. Though MPS is a common type of non-articular pain, its pathophysiology is only beginning to be understood due to its enormous complexity. MPS is characterized by the presence of myofascial trigger points (MTrPs), which are defined as hyperirritable nodules located within a taut band of skeletal muscle. MTrPs may be active (spontaneously painful and symptomatic) or latent (non-spontaneously painful). Painful MTrPs activate muscle nociceptors that, upon sustained noxious stimulation, initiate motor and sensory changes in the peripheral and central nervous systems. This process is called sensitization. In order to investigate the peripheral factors that influence the sensitization process, a microdialysis technique was developed to quantitatively measure the biochemical milieu of skeletal muscle. Biochemical differences were found between active and latent MTrPs, as well as in comparison with healthy muscle tissue. In this paper we relate the findings of elevated levels of sensitizing substances within painful muscle to the current theoretical framework of muscle pain and MTrP development.     

Structural integration—developments in Ida Rolf's ‘recipe’—Part 3. An alternative form

Structural Integration (SI), known popularly as ‘rolfing’,¹ is a systematic programme of connective tissue manipulation. Parts 1 and 2 of this series defined the scope of SI practice, and presented a general outline of Dr. Rolf's multi-session protocol of the SI ‘Recipe’. In this final part we present an alternate version based on longitudinal myofascial continuities.     

Effect of self-myofascial release on myofascial pain,muscle flexibility,and strength: A narrative review

Background

Numerous techniques have been employed to treat myofascial pain syndrome. Self-myofascial release (SMFR) is a relatively new technique of soft tissue mobilization. The simplicity and portability of the SMFR tools allow it to be easily implemented in any type of fitness or rehabilitation program. It is an active method and can be used by anyone at home or at the workplace.

Orthopaedic manual physical therapists-champions in education,manipulative therapy and movement control restoration

Abstract

Objectives:

Myofascial trigger points (MTrPs) are considered the principal clinical feature of myofascial pain syndrome (MPS). An MTrP consists of spot tenderness within a taut band of muscle fibers and its stimulation can produce both local and referred pain. The clinical diagnosis of MPS depends on correct history taking and a physical examination aimed at identifying the presence of MTrP. The purpose of this study was to investigate the intra-rater reliability of a palpation protocol used for locating an MTrP in the upper trapezius muscle.

Methods:

Twenty-four subjects with MTrP in the upper trapezius muscle were examined by an experienced physiotherapist. During each of eight experimental sessions, subjects were examined twice in randomized order using a palpation protocol. An anatomical landmark system was defined and the MTrP location established using X and Y values.

Results:

The intraclass correlation coefficient ICC_(1,1) values were 0·62 (95% CI: 0·30–0·81) for X and 0·81 (95% CI: 0·61–0·91) for Y. The Bland–Altman plots for X and Y showed a mean of difference of 0·04 and ?0·2 mm, respectively. Limits of agreement for X ranged from ?26·3 to 26·2 mm and for Y from ?27 to 26·4 mm.

Discussion:

The ICC_(1,1) for the observed values revealed a moderate to high correlation and the Bland–Altman analysis showed means of difference very close to zero with narrow limits of agreement. An experienced physiotherapist can reliably identify MTrP locations in upper trapezius muscle using a palpation protocol.     

实时组织弹性成像指导针刺激痛点治疗肌筋膜疼痛的疗效初探

目的应用实时组织弹性成像(RTE)确定肌筋膜激痛点(MTrPs),探讨其引导针刺治疗肌筋膜疼痛综合征(MPS)的应用价值。方法选择我院斜方肌MPS患者60例,按随机数字表法分为RTE组和传统针刺组各30例,比较两组患者治疗前后MTrPs弹性评分、疼痛评分的差异。对患者随访1年,比较两组患者的治疗效果及远期预后。结果两组治疗后MTrPs的弹性评分比较,差异有统计学意义(P<0.05)。RTE组治疗后视觉模拟评分(VAS)和疼痛评定指数(PRI)分别为(3.02±0.54)分、(3.34±0.62)分,均明显低于传统针刺组(3.89±0.36)分、(3.76±0.34)分,差异均有统计学意义(均P<0.05)。随访结果显示,RTE组的显效率为86.7%,累计无复发率为93.3%,传统针刺组的显效率为60.0%,累计无复发率为57.1%,两组比较差异均有统计学意义(均P<0.05)。结论RTE指导针刺MTrPs治疗MPS的疗效及预后均明显优于传统触诊法针刺,具有重要的临床价值。     

Expert consensus on the diagnosis and treatment of myofascial pain syndrome

Myofascial pain syndrome (MPS) is characterized by myofascial trigger points and fascial constrictions. At present, domestic and foreign scholars have not reached a consensus on the etiology and pathogenesis of MPS. Due to the lack of specific laboratory indicators and imaging evidence, there is no unified diagnostic criteria for MPS, making it easy to confuse with other diseases. The Chinese Association for the Study of Pain organized domestic experts to formulate this Chinese Pain Specialist Consensus on the diagnosis and treatment of MPS. This article reviews relevant domestic and foreign literature on the definition, epidemiology, pathogenesis, clinical manifestation, diagnostic criteria and treatments of MPS. The consensus is intended to normalize the diagnosis and treatment of MPS and be used by first-line doctors, including pain physicians to manage patients with MPS.     

Intra-rater reliability of an experienced physiotherapist in locating myofascial trigger points in upper trapezius muscle

Objectives:

Myofascial trigger points (MTrPs) are considered the principal clinical feature of myofascial pain syndrome (MPS). An MTrP consists of spot tenderness within a taut band of muscle fibers and its stimulation can produce both local and referred pain. The clinical diagnosis of MPS depends on correct history taking and a physical examination aimed at identifying the presence of MTrP. The purpose of this study was to investigate the intra-rater reliability of a palpation protocol used for locating an MTrP in the upper trapezius muscle.

Methods:

Twenty-four subjects with MTrP in the upper trapezius muscle were examined by an experienced physiotherapist. During each of eight experimental sessions, subjects were examined twice in randomized order using a palpation protocol. An anatomical landmark system was defined and the MTrP location established using X and Y values.

Results:

The intraclass correlation coefficient ICC_(1,1) values were 0.62 (95% CI: 0.30–0.81) for X and 0.81 (95% CI: 0.61–0.91) for Y. The Bland–Altman plots for X and Y showed a mean of difference of 0.04 and −0.2 mm, respectively. Limits of agreement for X ranged from −26.3 to 26.2 mm and for Y from −27 to 26.4 mm.

Discussion:

The ICC_(1,1) for the observed values revealed a moderate to high correlation and the Bland–Altman analysis showed means of difference very close to zero with narrow limits of agreement. An experienced physiotherapist can reliably identify MTrP locations in upper trapezius muscle using a palpation protocol.     

The spinal cord connections of the myofascial trigger spots.

BACKGROUND: Recent electrophysiological studies revealed that endplate noise (EPN) could be specifically recorded from a myofascial trigger point (MTrP) region. EPN has been considered as the focal graded potentials due to excessive acetylcholine release in neuromuscular junction. A recent histological study has demonstrated a free nerve ending at the vicinity of the site, from where EPN could be recorded in an MTrP region. However, the sensory (afferent) and the motor (efferent) connections between an MTrP and the spinal cord still has never been fully studied. AIMS: The aim of this study was to delineate both motor and sensory connections between an MTrP and the spinal cord by applying the stain with horseradish peroxidase (HRP). METHODS: Nine Wistar rats were studied. When the rat was anesthetized, its biceps femoris muscles were exposed for localizing the myofascial trigger spot (MTrS, equivalent to MTrP in human). In one side, a monopolar Teflon-coated, hollow-needle electrode was used for searching EPN in an MTrS region, and then HRP was injected via this hollow-needle electrode into the site where EPN was recorded. HRP was also injected into a normal (non-taut band, non-MTrS) site in the contralateral side to obtain the control data. Two days after HRP injection, the rats were sacrificed and their spinal cords and dorsal root ganglia (DRG) were sectioned for the identification of the sites where neurons were labeled with HRP. RESULTS: The HRP-labeled neurons were found in the ventral horn of the spinal cord and in the DRG over L3, L4, and L5, while most were found in the L5 level. The mean numbers of HRP-labeled neurons in the EPN side looked smaller than that in the control side, but the difference did not reach statistically significant level (P>0.05). The mean values of the diameters of the HRP-labeled neurons in the DRG were not significantly different between the EPN side and the control side (P>0.05). However, HRP-neurons in the ventral horn of the spinal cord in the EPN side showed mild tendency to be smaller than that in the control side. CONCLUSIONS: The spinal cord connections of an MTrS are basically similar to that for a normal tissue region. The motor neurons related to MTrS tended to be smaller in their diameters. The findings in this study further supported the previously proposed hypotheses for the pathogenesis of an MTrP.     

Myofacial trigger point

Myofascial trigger points are one of the most common causes of acute and chronic musculoskeletal pain. Contrary to popular belief, myofascial trigger points can be primary, and not just secondary due to other non-muscular pathology. The main criteria, for which the interrater reliability has been established, include the presence of a taut band, a local twitch response, an exquisite tender point within the taut band, and typical referred pain patterns. During the past few years, the actual existence and high prevalence of myofascial trigger points are supported by worldwide research findings. The “energy crisis theory” describes the peripheral pathophysiologic events of myofascial trigger points. In most cases myofascial trigger points can be treated successfully both in acute and chronic pain syndromes. Several treatment options are available including manual therapy, injections, dry needling, and electrotherapeutic modalities. In some cases neuroplastic changes in the spinal dorsal horn and sympathetic-afferent coupling play a role in the development of chronic pain syndromes and complicate the treatment.      

颈后肌筋膜疼痛综合症射频热凝治疗

目的:总结射频热凝治疗颈后肌筋膜疼痛综合症的临床效果.方法:32例颈后肌筋膜疼痛综合症患者,以颈后肌群压痛点为穿刺点,穿刺针抵达骨质后,调节热凝温度为75℃,时间为30秒,行穿刺点射频热凝;观察治疗前、治疗后1周、1月和3个月VAS评分、疼痛缓解优良率和镇痛药使用情况.结果:治疗前、治疗后1周、1月和3个月VAS评分分别是8.1±0.9、7.3±1.2、3.8±1.1、1.5±1.2;疼痛程度在治疗后1个月和3个月均较治疗前有明显缓解(P＜0.01);治疗后1周内使用止痛药人次为85%,1个月后为10%(P＜0.05),3个月后全部停止痛药.结论:射频热凝治疗颈肌筋膜疼痛综合症创伤微小、安全和疗效确切.     

Immediate effects of diaphragmatic myofascial release on the physical and functional outcomes in sedentary women: A randomized placebo-controlled trial

Background

Although diaphragmatic myofascial release techniques are widely used in clinical practice, few studies have evaluated the simultaneous acute effects of these techniques on the respiratory and musculoskeletal systems.

Dry needling of the trapezius muscle in office workers with neck pain: a randomized clinical trial

Background: Neck pain is a frequent complaint in office workers. This pain can be caused by myofascial trigger points (MTrPs) in the trapezius muscle. This study aimed to determine the effectiveness of deep dry needling (DDN) of active MTrPs in the trapezius muscle.

Methods: A randomized, single blinded clinical trial was carried out at the Physical Therapy Department at Physiotherapy in Women's Health Research Group at Physical Therapy Department of University of Alcalá, in Alcalá de Henares, Madrid, Spain. Forty-four office workers with neck pain and active MTrPs in the trapezius muscle were randomly allocated to either the DDN or the control group (CG). The participants in the DDN group were treated with DDN of all MTrPs found in the trapezius muscle. They also received passive stretch of the trapezius muscle. The CG received the same passive stretch of the trapezius muscle only. The primary outcome measure was subjective pain intensity, measured using a visual analogue scale (VAS). Secondary outcomes were pressure pain threshold (PPT), cervical range of motion (CROM) and muscle strength. Data were collected at baseline, after interventions and 15?days after the last treatment.

Results: Differences were found between the DDN group and the CG for the VAS (P?P?P?P?Discussion: Deep dry needling and passive stretch seems to be more effective than passive stretch only. The effects are maintained in the short term. The results support the use of DDN in the management of trapezius muscle myofascial pain syndrome in neck pain.