Acute Compartment Syndrome and Rhabdomyolysis Caused by a Single Electrical Muscle Stimulation in a 46-Year-Old Female Professional Athlete With Fibromyalgia, Chronic Fatigue Syndrome, and Myofascial Disorder: A Case Report.

ABSTRACT: Electrical muscle stimulation (EMS) training has been recognized as an effective modality for improving body composition, enhancing body strength, and facilitating injury recovery. However, individuals who are new to EMS training and those with certain chronic diseases should exercise caution due to the increased risk of rhabdomyolysis. This case report describes the occurrence of rhabdomyolysis and gluteal compartment syndrome following a single session of EMS training in a 46-year-old Caucasian female professional athlete. The patient was successfully managed with intensive intravenous fluid therapy and sodium bicarbonate supplementation, along with close monitoring of electrolytes and renal function. Electrical muscle stimulation training poses an increased risk of severe complications in individuals with chronic diseases and myopathy. Therefore, careful subject selection is required for EMS training in individuals with chronic diseases and myopathy to prevent common side effects. For individuals trying EMS training for the first time, it is recommended to avoid high-frequency EMS exercises.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice.

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines). PREOPERATIVE PATIENTS' INFORMATION: Each patient must be informed concerning the risks associated with POP surgery (EO). HEMORRHAGE, HEMATOMA: Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO). BLADDER INJURY: When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO). URETER INJURY: After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO). RECTAL INJURY: Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO). VAGINAL WALL INJURY: After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO). MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS): Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient. BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM: Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO). URINARY RETENTION: Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO). POSTOPERATIVE PAIN: Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO). POSTOPERATIVE DYSPAREUNIA: When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO). VAGINAL MESH EXPOSURE: To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO). SUTURE THREAD VAGINAL EXPOSURE: For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed. BLADDER AND URETERAL MESH EXPOSURE: When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis.

Trigeminal neuralgia (TN), the most common form of severe facial pain, may be confused with an ill-defined persistent idiopathic facial pain (PIFP). Facial pain is reviewed and a detailed discussion of TN and PIFP is presented. A possible cause for PIFP is proposed. (1) Methods: Databases were searched for articles related to facial pain, TN, and PIFP. Relevant articles were selected, and all systematic reviews and meta-analyses were included. (2) Discussion: The lifetime prevalence for TN is approximately 0.3% and for PIFP approximately 0.03%. TN is 15-20 times more common in persons with multiple sclerosis. Most cases of TN are caused by neurovascular compression, but a significant number are secondary to inflammation, tumor or trauma. The cause of PIFP remains unknown. Well-established TN treatment protocols include pharmacotherapy, neurotoxin denervation, peripheral nerve ablation, focused radiation, and microvascular decompression, with high rates of relief and varying degrees of adverse outcomes. No such protocols exist for PIFP. (3) Conclusion: PIFP may be confused with TN, but treatment possibilities differ greatly. Head and neck muscle myofascial pain syndrome is suggested as a possible cause of PIFP, a consideration that could open new approaches to treatment.

Myofascial pain, widespread pressure hypersensitivity, and hyperalgesia in the face, neck, and shoulder regions, in survivors of head and neck cancer.

PURPOSE: Medical treatment for head and neck cancer may induce the presence of inflammation, pain, and dysfunction. The purpose of the current study was to assess the presence of myofascial trigger points (TrPs) and their relationship with widespread pressure hypersensitivity and hyperalgesia in survivors of head and neck cancer (sHNC). METHODS: TrPs and pressure-pain thresholds (PPTs) were quantified in different muscles/joints in the head and neck of 30 sHNC (59.45 ± 13.13 years) and 28 age- and sex-matched controls (58.11 ± 12.67 years). RESULTS: The sHNC had more TrPs in all muscles on the affected side (p < 0.05) than did the healthy controls, and in the temporalis, masseter, and suboccipitalis muscles on the unaffected side (p < 0.05). They also had lower PPTs in all places (p < 0.05) except for the temporalis muscle (p = 0.114) and C5-C6 joint (p = 0.977). The intensity of cervical pain correlated positively with the presence of upper trapezius TrPs. CONCLUSIONS: sHNC suffering cervical and/or temporomandibular joint pain have multiple active TrPs and experience widespread pressure hypersensitivity and hyperalgesia, suggestive of peripheral and central sensitization.

The Greater Occipital Nerve and Obliquus Capitis Inferior Muscle: Anatomical Interactions and Implications for Occipital Pain Syndromes.

BACKGROUND: The compression/injury of the greater occipital nerve has been identified as a trigger of occipital headaches. Several compression points have been described, but the morphology of the myofascial unit between the greater occipital nerve and the obliquus capitis inferior muscle has not been studied yet. METHODS: Twenty fresh cadaveric heads were dissected, and the greater occipital nerve was tracked from its emergence to its passage around the obliquus capitis inferior. The intersection point between the greater occipital nerve and the obliquus capitis inferior, and the length and thickness of the obliquus capitis inferior, were measured. In addition, the nature of the interaction and whether the nerve passed through the muscle were also noted. RESULTS: All nerves passed either around the muscle loosely (type I), incorporated in the dense superficial muscle fascia (type II), or directly through a myofascial sleeve within the muscle (type III). The obliquus capitis inferior length was 5.60 ± 0.46 cm. The intersection point between the obliquus capitis inferior and the greater occipital nerve was 6.80 ± 0.68 cm caudal to the occiput and 3.56 ± 0.36 cm lateral to the midline. The thickness of the muscle at its intersection with the greater occipital nerve was 1.20 ± 0.25 cm. Loose, tight, and intramuscular connections were found in seven, 31, and two specimens, respectively. CONCLUSIONS: The obliquus capitis inferior remains relatively immobile during traumatic events, like whiplash injuries, placing strain as a tethering point on the greater occipital nerve. Better understanding of the anatomical relationship between the greater occipital nerve and the obliquus capitis inferior can be clinically useful in cases of posttraumatic occipital headaches for diagnostic and operative planning purposes.

Interventions for myofascial pain syndrome in cancer pain: recent advances: why, when, where and how.

PURPOSE OF REVIEW: Pain is one of the most feared and most common symptoms of cancer, experienced by 38-85% of patients. Pain in terminally ill cancer patients is a multidimensional experience caused by a diverse array of factors - cancer itself, its treatment or other causes. Studies have shown a high incidence of myofascial pain syndrome (MPS) in patients with cancer and the knowledge of myofascial trigger points (MTrPs) is important to address and manage existing pain, and to prevent the recurrence of pain. This review aims to summarize recent advances in interventions for managing MPS in patients with cancer. RECENT FINDINGS: Database searches were conducted on MEDLINE, CINAHL, and Google Scholar to locate all studies published from inception until April 2019 using the keywords cancer pain, myofascial pain, TrPs with emphasis of any methodological quality that included interventions for MPS. MPS in advanced cancer patients are more commonly observed along with other cancer pains rather than independently with a prevalence of 11.9-48% in those patients diagnosed with cancer of head and neck and breast cancer. SUMMARY: Interventional therapies employing ultrasound guided injection of the MTrPs is gaining popularity in the management of MPS in cancer pain and may be a better alternative than the use of opioid analgesics in the multidisciplinary management.

The myofascial component of the pain in the painful shoulder of the hemiplegic patient

OBJECTIVES: Poststroke shoulder pain occurs very frequently and compromises function and quality of life. Because treatment depends on a multidisciplinary approach, it is desirable to optimize effectiveness. Myofascial pain syndrome is defined by the presence of trigger points that can also be found in spastic stroke patients. The aim of this study was to evaluate the frequency of myofascial pain in the shoulder girdle muscles in patients with poststroke shoulder pain and to document the clinical and functional results obtained with specific treatment for this condition. METHODS: Spastic stroke hemiplegic patients undergoing rehabilitation at the Rehabilitation Center of the Hospital das Clínicas of the Ribeirão Preto Medical School of the University of São Paulo were evaluated regarding the intensity and characteristics of shoulder pain, previous therapeutic interventions, shoulder goniometry and the presence of trigger points. Patients underwent trigger point blockade by intramuscular infiltration of 1% lidocaine. The evaluation and treatment procedures were repeated in the subsequent 3 weeks as long as the pain intensity was greater than 5 on a visual analog scale (VAS). In the fourth week, the evaluation procedures were repeated. Patients who were in a multiprofessional rehabilitation program were instructed to continue the treatment, and the others received complementary therapeutic advice if necessary to initiate it. The evaluations were performed at 0, 1, and 3 weeks and after 4 months. RESULTS: Twenty-one patients (13 men; age=67.8±10.2 years; right hemiparesis: 11) participated in the study, and there was a reduction in pain assessed by VAS from baseline (7.6±2.7) to the first week (5.8±3.6; p<0.05) through the end of the third week (5.2±3.5; p<0.05), but not at the end of four months (6.6±2.9; p=0.11). Good responders had significantly lower pain levels after the third week and presented with a larger range of motion for passive abduction by the end of 4 months. These results demonstrate that the myofascial component of pain should be considered in poststroke shoulder pain and that its treatment may be a pathway for the rapid and long-lasting relief of symptoms. CONCLUSION: Trigger point blockade with lidocaine can reduce pain perception in spastic hemiplegic shoulder in as much as 50% of stroke survivors for four months.

The Role of Stress in the Etiology of Oral Parafunction and Myofascial Pain.

Oral parafunction during waking comprises possible behaviors that can be measured with a comprehensive checklist or behavioral monitoring. Multiple studies lead to largely consistent findings: stressful states can trigger parafunctional episodes that contribute to myofascial pain. However, this simple causal pathway coexists with at least 3 other pathways: anxiety and stress are potent direct contributors to pain, pain results in maladaptive behaviors such as parafunction, and parafunction may be a coping response to potential threat coupled with hypervigilance and somatosensory amplification. Awake parafunction remains an important risk factor for myofascial pain onset and overuse models alone of causation are insufficient.

Identification of Myofascial Trigger Points in Breast Cancer Survivors with Upper Limb Pain: Interrater Reliability.

Objective: Despite the increasing awareness of the contribution of myofascial dysfunctions to upper limb pain in breast cancer survivors, reliability of the identification of myofascial trigger points (MTPs) in this population has not yet been investigated. Therefore, the aim of the present study was to investigate the interrater reliability of the identification of MTPs by palpation at the upper limb region in breast cancer survivors with upper limb pain. Design: Interrater reliability study. Setting: University Hospitals Leuven, Belgium. Subjects: Thirty breast cancer survivors with pain at the upper limb region. Methods: Nine muscles (upper trapezius, levator scapulae, infraspinatus, supraspinatus, teres major and minor, subscapularis, pectoralis major, and scalene muscles) at the operated side were examined. The weighted kappa (WK) coefficient and Absolute Agreement with 95% confidence intervals were calculated. Results: Moderate agreement was found for all examined upper limb muscles (WK = 0.41-0.60), except for the trapezius muscle, for which the agreement was almost perfect (WK = 0.83), and the supraspinatus muscle (WK = 0.23), for which the agreement was only fair. Conclusions: For most muscles, moderate interrater reliability for the identification of MTPs by palpation in breast cancer survivors with upper limb pain was found. Therefore, we concluded that the identification of MTPs by palpation may add to the diagnosis of the myofascial pain syndrome in breast cancer survivors.

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

PURPOSE: To investigate the concurrent, face and content validity of an evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool). METHODS: 1) Concurrent validity of the MAP-BC evaluation tool was investigated by exploring correlations (Spearman's rank Correlation Coefficient) between the subjective scores (0 -no adhesions to 3 -very strong adhesions) of the skin level using the MAP-BC evaluation tool and objective elasticity parameters (maximal skin extension and gross elasticity) generated by the Cutometer Dual MPA 580. Nine different examination points on and around the mastectomy scar were evaluated. 2) Face and content validity were explored by questioning therapists experienced with myofascial therapy in breast cancer patients about the comprehensibility and comprehensiveness of the MAP-BC evaluation tool. RESULTS: 1) Only three meaningful correlations were found on the mastectomy scar. For the most lateral examination point on the mastectomy scar a moderate negative correlation (-0.44, p = 0.01) with the maximal skin extension and a moderate positive correlation with the resistance versus ability of returning or 'gross elasticity' (0.42, p = 0.02) were found. For the middle point on the mastectomy scar an almost moderate positive correlation with gross elasticity was found as well (0.38, p = 0.04) 2) Content and face validity have been found to be good. Eighty-nine percent of the respondent found the instructions understandable and 98% found the scoring system obvious. Thirty-seven percent of the therapists suggested to add the possibility to evaluate additional anatomical locations in case of reconstructive and/or bilateral surgery. CONCLUSIONS: The MAP-BC evaluation tool for myofascial adhesions in breast cancer patients has good face and content validity. Evidence for good concurrent validity of the skin level was found only on the mastectomy scar itself.

Ischemic compression and kinesiotherapy on chronic myofascial pain in breast cancer survivors.

OBJECTIVE: assess the effects of ischemic compression and kinesiotherapy on the rehabilitation of breast cancer survivors with chronic myofascial pain. METHODS: A randomized, controlled, blinded clinical trial was performed with 20 breast cancer survivors with myofascial trigger point in the upper trapezius muscle. Patients were randomly allocated to ischemic compression + kinesiotherapy (G1, n = 10) and kinesiotherapy (G2, n = 10). Both groups were submitted to 10 sessions of treatment. The variables evaluated were: Numeric Rating Scale, Pain Related Self-Statement Scale, pressure pain threshold, Functional Assessment of Cancer Therapy-Breast and Infrared thermography. RESULTS: A significant reduction (p < 0.05) was observed in pain intensity after 10 sessions in Groups 1 and 2, a significant increase (p < 0.05) in pressure pain threshold in both the operated and non-operated side after 10 sessions for Group 1. CONCLUSION: Ischemic compression associated with kinesiotherapy increases the pressure pain threshold on the myofascial trigger point in the upper trapezius muscle and reduces the intensity of pain in breast cancer survivors with myofascial pain.

Ultrasound-Guided Intra-articular Injection of the Radio-ulnar and Radio-humeral Joints and Ultrasound-Guided Dry Needling of the Affected Limb Muscles to Relieve Fixed Pronation Deformity and Myofascial Issues around the Shoulder, in a Case of Complex Regional Pain Syndrome Type 1.

BACKGROUND: Complex regional pain syndrome (CRPS) occurs due to different pathophysiological mechanisms. Presently there is no description of definitive treatment that can resolve the especially recalcitrant motor issues of disability in CRPS type 1 (CRPS-1). CASE REPORT: We have herein described the successful management of motor disability with a multimodal approach in a patient with CRPS-1 that occurred as a result of a fracture sustained in the lower end of the radius. Sensory/sudomotor/vasomotor symptoms were relieved completely by medications and stellate ganglion block in 2 weeks. Ultrasound-guided dry needling secured near-complete improvement of shoulder and hand movements in 45 days. Ultrasound guided intra-articular (radio-ulnar and radio-humeral joint) injections with steroid reduced residual pain and improved forearm movements by 50% initially. The patient continued to receive regular sessions of dry needling, physiotherapy, and cognitive behavioral therapy. By the end of 1 year, the functions of the limb improved remarkably, as did the functional outcome scores. CONCLUSION: In this patient with CRPS-1, intra-articular injections with steroid reduced nociception in the affected local structures and sensitization in the nervous system; dry needling resolved the myofascial issues; sustained physiotherapy maintained the motor recovery; and behavioral therapy techniques addressed the cognitive and life stress issues. It was concluded that the presenting symptoms in this case were a consequence of interactions between humoral, nervous, and myofascial systems.

Low 25-Hydroxyvitamin D and Myofascial Pain: Association of Cancer, Colon Polyps, and Tendon Rupture.

BACKGROUND: Myofascial pain that has been associated with cancer and increased risk of morbidity and mortality in cancer patients is intrinsically associated with low magnesium and low 25-hydroxyvitamin D (25(OH)D). Therefore, this physical finding was used as a clinical diagnostic proxy. OBJECTIVE: The objective of this study was to assess the association and prevalence of disease in individuals with myofascial pain and low 25(OH)D in a county with low magnesium in the drinking water. DESIGN: This is a retrospective cross-sectional study of a chart review of 269 subjects to assess subjects presenting with myofascial pain (assessed by tender trigger points) and 25(OH)D concentrations below 30 ng/mL or a history of 25(OH)D deficiency compared to those without these exposures. RESULTS: The association between the exposure of low 25(OH)D levels and myofascial pain was compared to all cancers, colon polyps, and tendon ruptures. The odds of having cancer with the combined exposures was 10.14 times the odds of not having either exposure (95% confidence interval [CI], 5.08, 20.25, p < 0.001). For adenomatous colon polyps, the odds ratio (OR) was 7.24 (95% CI, 3.83, 13.69, p < 0.001), and for tendon rupture, the OR was 8.65 (95% CI, 3.76, 19.94, p < 0.001). Of 80 subjects who had both myofascial pain and 25(OH)D less than 30 ng/mL, 74 were tested for red blood cell (RBC) magnesium. Half of those subjects had RBC magnesium concentrations < 4.6 mg/dL, and 23% had levels below the reference range (4.0-6.4 mg/dL). CONCLUSION: Myofascial pain as assessed by tender trigger points and 25(OH)D deficiency showed a significant association with cancer, adenomatous colon polyps, and tendon rupture. Further studies to verify these results are needed, especially in areas where there is low magnesium in the drinking water.

Myofascial pain and fibromyalgia: two different but overlapping disorders.

There is good evidence supporting that people with fibromyalgia syndrome (FMS) exhibit central sensitization. The role of peripheral nociception is under debate in FMS. It seems that widespread pain experienced in FMS is considered multiple regional pains; therefore, several authors proposed that muscles play a relevant role in FMS. Trigger points (TrPs) have long been a contentious issue in relation to FMS. Preliminary evidence reported that the overall spontaneous pain is reproduced by referred pain from active TrPs, suggesting that FMS pain is largely composed of pain arising, at least partially, from TrPs. Finally, there is preliminary evidence suggesting that management of TrPs is able to modulate the CNS and is effective for reducing pain in FMS, although results are conflicting and future studies are clearly needed.

Myofascial pain syndrome after head and neck cancer treatment: Prevalence, risk factors, and influence on quality of life.

BACKGROUND: Patients undergoing treatment for head and neck cancer may develop myofascial pain syndrome as sequelae. The purpose of this study was to determine the prevalence, risk factors, and quality of life (QOL) related to myofascial pain syndrome. METHODS: This was a prospective study including patients with head and neck cancer with at least a 1-year disease-free interval. RESULTS: One hundred sixty-seven patients were analyzed, and myofascial pain syndrome was diagnosed in 20 (11.9%). In the multivariate analysis, hypopharyngeal tumors (odds ratio [OR] = 6.35; 95% confidence interval [CI] = 1.58-25.56) and neck dissection (OR = 3.43; 95% CI = 1.16-10.17) were independent factors for myofascial pain syndrome. The pain (p < .001) and shoulder domain (p < .001) as well as overall University of Washington Quality of Life (UW-QOL) score (p = .006) were significantly lower in the patients with myofascial pain syndrome. CONCLUSION: Myofascial pain syndrome was observed in 1 of 9 patients after head and neck cancer treatment and a worse QOL was observed among them. Tumor site and neck dissection were found to be risk factors for myofascial pain syndrome.

The failed back surgery syndrome: pitfalls surrounding evaluation and treatment.

This article describes the costs and risk factors for failed back surgery syndrome and reviews the diagnosis and treatment strategies commonly used to address this syndrome. The purpose of this review is to describe some of the treatment pitfalls associated with these approaches from a physiatric perspective.

Home electroacupuncture for persistent postsurgical pain: a patient's report.

A 30-year-woman presented with iatrogenic myofascial facial pain of 12 months' duration after surgical treatment for bilateral temporomandibular joint dysfunction. Limited response to manual acupuncture was followed by a trial of electroacupuncture. Response to electroacupuncture was limited in duration and one option was to teach her partner to perform electroacupuncture at home. The patient and partner, trained in beauty therapy, embraced this idea and it proved equally effective as therapist-provided acupuncture. We describe this case report from the perspective of the patient, caregiver or acupuncture partner and therapist. Home electroacupuncture seems to be safe, acceptable and practicable as a maintenance treatment for patients with persistent postsurgical pain of myofascial origin.

TMD before and after correction of dentofacial deformities by orthodontic and orthognathic treatment.

The aims of the study were to investigate the alteration of temporomandibular disorders (TMD) after correction of dentofacial deformities by orthodontic treatment in conjunction with orthognathic surgery; and to compare the frequency of TMD in patients with dentofacial deformities with an age and gender matched control group. TMD were evaluated in 121 consecutive patients (treatment group), referred for orthognathic surgery, by a questionnaire and a clinical examination. 18 months after treatment, 81% of the patients completed a follow-up examination. The control group comprised 56 age and gender matched subjects, of whom 68% presented for follow-up examination. TMD were diagnosed according to research diagnostic criteria for TMD. At baseline examination, the treatment group had a higher frequency of myofascial pain (P=.035) and arthralgia (P=.040) than the control group. At follow-up, the frequencies of myofascial pain, arthralgia and disc displacement had decreased in the treatment group (P=.050, P=.004, P=.041, respectively). The frequency of TMD was comparable in the two groups at follow-up. Patients with dentofacial deformities, corrected by orthodontic treatment in conjunction with orthognathic surgery, seem to have a positive treatment outcome in respect of TMD pain.

Effectiveness of water physical therapy on pain, pressure pain sensitivity, and myofascial trigger points in breast cancer survivors: a randomized, controlled clinical trial.

OBJECTIVE: To evaluate the effects of an 8-week water physical therapy program on cervical and shoulder pain, pressure sensitivity, and the presence of trigger points (TrPs) in breast cancer survivors. DESIGN: Randomized, controlled trial. SETTING: To date, no study has investigated effects of water therapy in breast cancer. PATIENTS: Sixty-six breast cancer survivors were randomly assigned into two groups: WATER group, who received a water exercise program or CONTROL group who received the usual care treatment for breast cancer. INTERVENTIONS: The WATER therapy program consisted of 24 sessions (3 times/week over 8 weeks) of low-intensity exercises in a warm pool (32°C). Each session included 10-minute warm-up period; 35 minutes of aerobic, low-intensity endurance, and core stability training; and a 15-minute cool-down period (stretching and relaxation). OUTCOMES: Neck and shoulder pain (visual analog scale, 0-100 mm), pressure pain thresholds (PPTs) over C5-C6 zygapophyseal joints, deltoid muscles, second metacarpal, and tibialis anterior muscles, and the presence of TrPs in cervical-shoulder muscles were assessed at baseline and after the 8-week program by an assessor blinded to treatment allocation. RESULTS: The WATER group demonstrated a between-group improvement for neck pain of -31 mm (95% confidence interval [CI]-49 to -22, P < 0.001; effect size 1.1, 0.81-1.75) and for shoulder-axillary of -19 mm (-40 to -04, P = 0.046; effect size 0.70, 0.14-1.40). Improvements were also noted for PPT levels over C5-C6 joints (between-group differences, affected side: 27.7 kPa, 95% CI 3.9-50.4; unaffected: 18.1 kPa, 95% CI 6.1-52.2). No between-group differences for PPT over the remaining points were observed (P > 0.05). Finally, patients in the WATER program showed a greater reduction of active TrPs as compared with the CONTROL group (P < 0.05). CONCLUSIONS: An 8-week water therapy program was effective for improving neck and shoulder/axillary pain, and reducing the presence of TrPs in breast cancer survivors as compared with usual care; however, no significant changes in widespread pressure pain hyperalgesia were found.

Development of active myofascial trigger points in neck and shoulder musculature is similar after lumpectomy or mastectomy surgery for breast cancer.

Our aim was to describe the differences in the presence of myofascial trigger points (TrPs) in neck and shoulder muscles after 2 surgery approaches for breast cancer: mastectomy or lumpectomy. Thirty-two women (mean age: 50 ± 7 years) who received lumpectomy, 16 women (mean age: 48 ± 10 years) who had received mastectomy after breast cancer, and 16 women (mean age: 49 ± 9 years) with breast cancer who had not received either surgical treatment, participated. Myofascial TrPs in the upper trapezius, sternocleidomastoid, levator scapulae, scalene, infraspinatus and pectoralis major muscles were bilaterally explored by an assessor blinded to the women's condition. TrPs were considered active when palpation reproduced local and referred pain symptoms recognized by the patient as familiar pain symptoms. The number of active TrPs within mastectomy (mean ± SD: 4.6 ± 1) and lumpectomy (mean ± SD: 4.5 ± 1) groups was significantly higher (P < 0.001) as compared to the control group (mean ± SD: 1.1 ± 1.3), but not significantly different between them (P = 0.641). Women who received either lumpectomy or mastectomy showed similar distribution of active TrPs and a higher prevalence of active TrPs as compared to the control group. Active TrPs in the pectoralis major muscle were the most prevalent in both surgery groups The number of active TrPs was weakly correlated with neck (r(s) = 0.385; P = 0.029) and shoulder/axillary (r(s) = 0.397; P = 0.024) pain intensity within the lumpectomy, but not the mastectomy group. This study found active TrPs in neck and shoulder musculature in women who had received lumpectomy or mastectomy. The induced local and referred pain pattern from active TrPs reproduced neck and shoulder/axillary symptoms and pain patterns in women after breast cancer surgery. Few active TrPs were found in a control group of women with breast cancer who had not received any surgical treatment.