Assessment of the Performance of Ultrasonography for Detecting Myofascial Trigger Points.

Needle electromyogram (EMG) research has suggested that endplate noise (EPN) is a characteristic of myofascial trigger points (MTrPs). Although several studies have observed MTrPs through ultrasonography, whether they are hyperechoic or hypoechoic in ultrasound images is still controversial. Therefore, this study determined the echogenicity of MTrP ultrasonography. In stage 1, the MTrP of rat masseter muscle was identified through palpation and marked. Needle EMG was performed to detect the presence of EPN. When EPN was detected, ultrasound scans and indwelling needles were used to identify the nodule with a different grayscale relative to that of its surrounding tissue, and the echogenicity of the identified MTrP was determined. In stage 2, these steps were reversed. An ultrasound scan was performed to detect the nodule at the marked site, and an EMG needle was inserted into the nodule to detect EPN. There were 178 recordings in each stage, obtained from 45 rats. The stage 1 results indicate that the MTrPs in ultrasound images were hypoechoic with a 100% sensitivity of assessment. In stage 2, the accuracy and precision of MTrP detection through ultrasonography were 89.9% and 89.2%, respectively. The results indicate that ultrasonography produces highly accurate and precise MTrP detection results.

Assessment of the effects of transforming growth factor beta1 (TGF-ß1)-Smad2/3 on fibrosis in rat myofascial trigger points using point shear wave elastography.

Background & Aims: Myofascial trigger points (MTrPs) are highly sensitive irritated points within a tense belt of skeletal muscle, and are the main cause of muscle pain and dysfunction. MTrPs can also cause paraesthesia and autonomic nervous dysfunction. Furthermore, long-term and chronic MTrPs can cause muscle atrophy and even disability, seriously affecting the quality of life and mental health of patients, and increasing the social and economic burden. However, to date, there have been few studies on fibrogenesis and changes in MTrPs. Therefore, this study investigated whether transforming growth factor beta1 (TGF-ß1)-Smad2/3 participates in the formation of MTrPs and how it affects fibrosis using point shear wave elastography. Methods: Forty Sprague‒Dawley rats were randomly divided into the MTrPs group and the control group. Blunt injury combined with eccentric exercise was used to establish an MTrPs model. Electromyography (EMG), haematoxylin and eosin (H&E) staining and transmission electron microscopy (TEM) were used to verify the model. The collagen volume fraction was measured by Masson staining, the protein expression of TGF-ß1 and p-Smad2/3 was measured by Western blotting (WB) and immunohistochemistry (IHC), and the shear wave velocity (SWV) was measured by point shear wave elastography. Results: EMG, H&E and TEM examination indicated that the modelling was successful. The collagen volume fraction and the protein expression of TGF-ß1 and p-Smad2/3 were higher in the MTrPs group than in the control group. The SWV of the MTrPs group was also higher than that of the control group. These differences suggest that MTrPs may exhibit fibrosis. The correlations between the collagen volume fraction and SWV and between the collagen volume fraction and TGF-ß1 were positive. Conclusion: Fibrotic conditions may be involved in the formation of MTrPs. Ultrasound point shear wave elastography and assessment of TGF-ß1 and p-Smad2/3 expression can reflect the degree of MTrPs fibrosis to some extent. Further exploration of the important role of TGF-ß1 and Smad2/3 in the pathogenesis of MTrPs will be of great significance for clinical treatment.

Assessment of Concordance between Chairside Ultrasonography and Digital Palpation in Detecting Myofascial Trigger Points in Masticatory Myofascial Pain Syndrome.

INTRODUCTION: Masticatory myofascial pain is a musculoligamentous syndrome that can mimic odontogenic pain. Pain referral to odontogenic structures can be traced to hyperirritated myofascial trigger points (MTrPs). This pragmatic study evaluated the concordance between ultrasonography and palpation in detecting MTrPs in the masseter and temporalis muscles. METHODS: Fifty-seven patients suspected to have temporomandibular disorder were included. MTrPs were palpated manually by expert clinicians. Ultrasonography was then performed by a blind sonographer. The quantity of MTrPs and the involved muscle sections, the pain occurrence, and the location of the MTrPs within the muscle sections were compared using the mean difference (MD) and concordance statistics (Cohen κ and the interclass correlation coefficient [ICC]) as applicable. RESULTS: Ultrasonography located MTrPs as 2.1 ± 1.3 mm2 hypoechoic nodules at a depth of 7 ± 3.3 mm. Ultrasonography moderately agreed with palpation on the quantity of MTrPs per patient (MD = 1; 95% confidence interval [CI], 0.06-1.9; ICC = 0.56; 95% CI, 0.32-0.72). Palpation detected marginally more involved muscle sections per patient (MD = 0.7; 95% CI, 0.06-1.34.05; ICC = 0.64; 95% CI, 0.44-0.77) with more pain occurrence per patient (MD = 1.4; 95% CI, 0.56-2.28; ICC = 0.13; 95% CI, -0.26 to 0.41). There was a discordance in the location of the MTrPs within the muscle sections per patient (κ = -0.46; 95% CI, -0.77 to -0.14). CONCLUSIONS: Ultrasonography and palpation concurred moderately to substantially on the quantity of MTrPs and the involved muscle sections but disagreed on the location of the MTrPs within the muscle sections. Ultrasonography has the potential as a chairside diagnostic aid to help clinicians determine an accurate diagnosis, enhance patient experience during examination, and avoid unnecessary treatments that can mitigate the risk of iatrogenic damage.

Quantitative Shear Wave Speed Assessment for Muscles With the Diagnosis of Taut Bands and/or Myofascial Trigger Points Using Probe Oscillation Shear Wave Elastography: A Pilot Study.

OBJECTIVE: To use probe oscillation shear wave elastography (PROSE) with two vibration sources to generate two shear waves in the imaging plane to quantitatively assess the shear wave speeds (SWSs) of muscles with and without the diagnosis of taut bands (TB) and/or myofascial trigger points (MTrPs). METHODS: Thirty-three patients were scanned with the PROSE technique. Shear waves were generated through continuous vibration of the ultrasound probe, while the shear wave motions were detected using the same probe. SWSs for the sides with and without TBs and/or MTrPs were computed and compared. The pressure pain thresholds (PPTs) were measured as an indicator of maximum pain tolerance of patients. The statistical differences between the SWSs with and without TBs and/or MTrPs with different PPT values were analyzed using the nonparametric Wilcoxon rank-sum test. RESULTS: The mean SWSs for the sides with TBs and/or MTrPs are faster than that of the contralateral side without TBs and/or MTrPs. A significant difference was observed between mean SWSs with and without TBs and/or MTrPs without any information of PPT, with rank-sum test P < .005. Additionally, with the information of PPT, a significant difference was observed between mean SWSs for the sides with and without TBs and/or MTrPs, for PPT values between 0 and 50 N/cm2 (P < .005), but for PPT values between 50 and 90 N/cm2 , it was difficult to differentiate mean SWSs with and without TBs and/or MTrPs. CONCLUSION: Our preliminary results show that SWSs measured from patients had a significant difference between the mean SWSs with and without TBs and/or MTrPs.

Assessment of Myofascial Trigger Points via Imaging: A Systematic Review.

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

Electromyographic Assessment of the Efficacy of Deep Dry Needling versus the Ischemic Compression Technique in Gastrocnemius of Medium-Distance Triathletes.

Several studies have shown that gastrocnemius is frequently injured in triathletes. The causes of these injuries are similar to those that cause the appearance of the myofascial pain syndrome (MPS). The ischemic compression technique (ICT) and deep dry needling (DDN) are considered two of the main MPS treatment methods in latent myofascial trigger points (MTrPs). In this study superficial electromyographic (EMG) activity in lateral and medial gastrocnemius of triathletes with latent MTrPs was measured before and immediately after either DDN or ICT treatment. Taking into account superficial EMG activity of lateral and medial gastrocnemius, the immediate effectiveness in latent MTrPs of both DDN and ICT was compared. A total of 34 triathletes was randomly divided in two groups. The first and second groups (n = 17 in each group) underwent only one session of DDN and ICT, respectively. EMG measurement of gastrocnemius was assessed before and immediately after treatment. Statistically significant differences (p = 0.037) were shown for a reduction of superficial EMG measurements differences (%) of the experimental group (DDN) with respect to the intervention group (ICT) at a speed of 1 m/s immediately after both interventions, although not at speeds of 1.5 m/s or 2.5 m/s. A statistically significant linear regression prediction model was shown for EMG outcome measurement differences at V1 (speed of 1 m/s) which was only predicted for the treatment group (R2 = 0.129; ß = 8.054; F = 4.734; p = 0.037) showing a reduction of this difference under DDN treatment. DDN administration requires experience and excellent anatomical knowledge. According to our findings immediately after treatment of latent MTrPs, DDN could be advisable for triathletes who train at a speed lower than 1 m/s, while ICT could be a more advisable technique than DDN for training or competitions at speeds greater than 1.5 m/s.

Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises.

BACKGROUND: It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for. METHODS: To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period. RESULTS: In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization. CONCLUSIONS: The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.

[Myofascial approach in tension-type headache management: a scientific assessment]. / Approche myofasciale dans la prise en charge des céphalées de tension†: ce que dit la science.

Tension-type headaches (TTH) are a very common condition. The most recent theories on TTH occurrences suggest that a myofascial component, through trigger points (TP), gives rise to pain signals from the periphery to the central nervous system (CNS). These nociception could lead to CNS sensitization and headaches. Studies show that identification and treatment of TP is a valid therapeutic option for TTH. Amongst the treatment techniques, dry needling (DN) and ischemic compression (IC) seem to be the most effective. These technics can be easily acquired and applied by any doctor.

Les céphalées de tension (CT) sont très fréquentes dans notre société. Les théories les plus récentes sur la génération des CT suggèrent que la composante myofasciale, via les points gâchette, ou trigger points (TP), soit à l'origine de signaux nociceptifs de la périphérie vers le système nerveux central (SNC). Cette nociception pourrait provoquer une sensibilisation du SNC et des céphalées. Les études montrent que pour les CT, l'identification et le traitement des TP sont des options thérapeutiques valables. Parmi les techniques de traitement, le dry needling (DN) et la compression ischémique (CI) semblent être les plus efficaces. Ces techniques peuvent être acquises rapidement et appliquées par tout médecin.

Quantitative magnetic resonance imaging of the upper trapezius muscles - assessment of myofascial trigger points in patients with migraine.

BACKGROUND: Research in migraine points towards central-peripheral complexity with a widespread pattern of structures involved. Migraine-associated neck and shoulder muscle pain has clinically been conceptualized as myofascial trigger points (mTrPs). However, concepts remain controversial, and the identification of mTrPs is mostly restricted to manual palpation in clinical routine. This study investigates a more objective, quantitative assessment of mTrPs by means of magnetic resonance imaging (MRI) with T2 mapping. METHODS: Ten subjects (nine females, 25.6 ± 5.2 years) with a diagnosis of migraine according to ICHD-3 underwent bilateral manual palpation of the upper trapezius muscles to localize mTrPs. Capsules were attached to the skin adjacent to the palpated mTrPs for marking. MRI of the neck and shoulder region was performed at 3 T, including a T2-prepared, three-dimensional (3D) turbo spin echo (TSE) sequence. The T2-prepared 3D TSE sequence was used to generate T2 maps, followed by manual placement of regions of interest (ROIs) covering the trapezius muscles of both sides and signal alterations attributable to mTrPs. RESULTS: The trapezius muscles showed an average T2 value of 27.7 ± 1.4 ms for the right and an average T2 value of 28.7 ± 1.0 ms for the left side (p = 0.1055). Concerning signal alterations in T2 maps attributed to mTrPs, nine values were obtained for the right (32.3 ± 2.5 ms) and left side (33.0 ± 1.5 ms), respectively (p = 0.0781). When comparing the T2 values of the trapezius muscles to the T2 values extracted from the signal alterations attributed to the mTrPs of the ipsilateral side, we observed a statistically significant difference (p = 0.0039). T2 hyperintensities according to visual image inspection were only reported in four subjects for the right and in two subjects for the left side. CONCLUSIONS: Our approach enables the identification of mTrPs and their quantification in terms of T2 mapping even in the absence of qualitative signal alterations. Thus, it (1) might potentially challenge the current gold-standard method of physical examination of mTrPs, (2) could allow for more targeted and objectively verifiable interventions, and (3) could add valuable models to understand better central-peripheral mechanisms in migraine.

Assessment of the Short-Term Effectiveness of Kinesiotaping and Trigger Points Release Used in Functional Disorders of the Masticatory Muscles.

Chronic face pain syndrome is a diagnostic and therapeutic problem for many specialists, and this proves the interdisciplinary and complex nature of this ailment. Physiotherapy is of particular importance in the treatment of pain syndrome in the course of temporomandibular joint functional disorders. In patients with long-term dysfunction of masticatory muscles, the palpation examination can localize trigger points, that is, thickening in the form of nodules in the size of rice grains or peas. Latent trigger points located in the muscles can interfere with muscular movement patterns, cause cramps, and reduce muscle strength. Because hidden trigger points can spontaneously activate, they should be found and released to prevent further escalation of the discomfort. Kinesiotaping (KT) is considered as an intervention that can be used to release latent myofascial trigger points. It is a method that involves applying specific tapes to the patient's skin in order to take advantage of the natural self-healing processes of the body. The aim of the study was to evaluate the effect of the kinesiotaping method and trigger points inactivation on the nonpharmacological elimination of pain in patients with temporomandibular disorders. The study was conducted in 60 patients (18 to 35 years old). The subjects were randomly divided into two subgroups of 30 people each. Group KT (15 women and 15 men) were subjected to active kinesiotaping application. Group TrP, composed of 16 women and 14 men, was subjected to physiotherapy with the release of trigger points by the ischemic compression method. The results show that the KT method and TrP inactivation brought significant therapeutic analgesic effects in the course of pain-related functional disorders of the muscles of mastication. The more beneficial outcomes of the therapy were observed after using the KT method, which increased the analgesic effect in dysfunctional patients.

Cost-effectiveness Evaluation of the Inclusion of Dry Needling into an Exercise Program for Subacromial Pain Syndrome: Evidence from a Randomized Clinical Trial.

Objective: To evaluate the cost-effectiveness of the inclusion of trigger point-dry needling (TrP-DN) into an exercise program for the management of subacromial pain syndrome. Methods: Fifty patients with unilateral subacromial pain syndrome were randomized with concealed allocation to exercise alone or exercise plus TrP-DN. Both groups were asked to perform an exercise program targeting the rotator cuff musculature twice daily for five weeks. Patients allocated to the exercise plus TrP-DN group also received dry needling during the second and fourth sessions. Societal costs and health-related quality of life (estimated by EuroQol-5D-5L) over a one-year follow-up were used to generate incremental cost per quality-adjusted life-year (QALY) ratios for each intervention. Results: Intention-to-treat analysis was possible for 48 (96%) of the participants. Those in the exercise group made more visits to medical doctors and received a greater number of other treatments (P < 0.001). The major contributor to societal costs (77%) was the absenteeism paid labor in favor of the exercise plus TrP-DN group (P = 0.03). The combination of exercise plus TrP-DN was less costly (mean difference cost/patient = €517.34, P = 0.003) than exercise alone. Incremental QALYs showed greater benefit for exercise plus TrP-DN (difference = 2.87, 95% confidence interval = 2.85-2.89). Therefore, the inclusion of TrP-DN into an exercise program was more likely to be cost-effective than an exercise program alone, with 99.5% of the iterations falling in the dominant area. Conclusions: The inclusion of TrP-DN into an exercise program was more cost-effective for individuals with subacromial pain syndrome than exercise alone. From a cost-benefit perspective, the inclusion of TrP-DN into multimodal management of patients with subacromial pain syndrome should be considered.

Prospective Audit of a Pathway for In-Patient Pain Management of Chronic Abdominal Pain: A Novel and Cost-Effective Strategy.

Background: Unexplained abdominal pain is a common cause of hospital admission and utilizes significant resource. Current in-patient pain management of acute exacerbation of chronic abdominal pain is primarily directed at pharmacological and psychological management strategies in this group of complex patients. We adopted a novel approach that proved to be both clinically effective and cost-effective. Design: Adult patients admitted to a surgical ward with acute exacerbation of chronic abdominal pain referred to in-patient pain management were prospectively audited over a two-year period at a single tertiary centre. Methods: Management strategy focused on a somatic source as the predominant pain generator. Patients were offered ultrasound-guided trigger point injection with steroids within 48 hours of referral and were discharged when pain control was achieved. Subsequent care by the pain physician included targeted treatment of somatic component (repeated trigger point injection with steroids or pulsed radiofrequency treatment of trigger points). Results: We audited 43 patients referred to the inpatient pain management service over a two-year period. Four patients refused to undergo the diagnostic trigger point injection. Three patients with active visceral disease had a transient response to the injection. Thirty-six patients were diagnosed with abdominal myofascial pain syndrome, and two-thirds of these patients were discharged home within 36 hours of the intervention. Conclusions: Abdominal myofascial pain syndrome is a poorly recognized cause of chronic abdominal pain, especially in patients with a past history of visceral inflammation. The novel strategy resulted in a significant reduction in opioid consumption, length of stay, and readmission rate.

The Relationship between Rate of Algometer Application and Pain Pressure Threshold in the Assessment of Myofascial Trigger Point Sensitivity.

BACKGROUND: Pressure algometry is a commonly employed technique in the assessment of both regional and widespread musculoskeletal pain. Despite its acceptance amongst clinicians and scientists, the relationship between rate of pressure application (RoA) and pain pressure threshold (PPT) remains poorly understood. We set out to test the hypothesis that a strong, positive, linear relationship exists between the RoA and the PPT within the infraspinatus of young healthy subjects. METHODS: Thirty-three participants were randomly recruited from the local university community. PPT measures were recorded from a clinically identified myofascial trigger point within the right infraspinatus muscle during pressure algometry. A total of 2 PPT measures were recorded using each of 3 different RoAs, including low (15 N/s), medium (35 N/s), and high (55 N/s). Three baseline trials were also conducted at 30 N/s. The Pearson's correlation coefficient between RoA and PPT was calculated for each subject and averaged across participants. RESULTS: The mean(SD) correlation between subjects was 0.77 (0.19), and the mean (SD) slope of the linear regression was 0.13 (0.09). CONCLUSION: Our results demonstrate that there is a strong, linear relationship between the RoA and PPT when using the pressure algometry technique. The low slope between RoA and PPT suggests clinicians can rely on PPT assessments despite small RoA fluctuations. Future research should explore this relationship further in a clinical population and in other muscles affected by chronic myofascial pain. Advancing cost-effective, reliable, and clinically feasible tools such as algometry is important to enhancing the diagnosis and management of chronic myofascial pain.

Reliability of assessment of upper trapezius morphology, its mechanical properties and blood flow in female patients with myofascial pain syndrome using ultrasonography.

OBJECTIVE: In the present study, the intra-rater reliability of upper trapezius morphology, its mechanical properties and intramuscular blood circulation in females with myofascial pain syndrome were assessed using ultrasonography. DESIGN: A total of 37 patients (31.05 ± 10 years old) participated in this study. Ultrasonography producer was set up in three stages: a) Gray-scale: to measure muscle thickness, size and area of trigger points; b) Ultrasound elastography: to measure muscle stiffness; and c) Doppler imaging: to assess blood flow indices. RESULTS: According to data analysis, all variables, except End Diastolic Velocity (EDV), had excellent reliability (>0.806). Intra-class Correlation Coefficient (ICC) for EDV was 0.738, which was considered a poor to good reliability. CONCLUSION: The results of this study introduced a reliable method for developing details of upper trapezius features using muscular ultrasonography in female patients. These variables could be used for objective examination and provide guidelines for treatment plans in clinical settings.

Assessment of Myofascial Trigger Points Using Ultrasound.

Myofascial pain syndrome is a common musculoskeletal pain disorder characterized by the presence of myofascial trigger points (MTrPs). The diagnosis of myofascial pain syndrome is currently made on clinical grounds. Numerous diagnostic criteria are used to identify myofascial pain syndrome, including the localization of MTrPs. Identifying the presence of MTrPs currently requires the physician to palpate the symptomatic region. Because the interrater reliability of the palpation technique has been found to be poor, numerous groups have been interested in finding objective imaging measures to localize the MTrP. This comprehensive review focuses on summarizing ultrasound imaging techniques that have shown promise in visually localizing the trigger point. The authors' literature search identified three sonographic approaches that have been used in MTrP localization: conventional gray-scale imaging, Doppler imaging, and elastographic ultrasound imaging. This review article explains the basic physics behind the imaging methods and summarizes the characteristics of the MTrP as identified by the ultrasonic techniques.

A socioeconomic analysis of surgical treatment of migraine headaches.

BACKGROUND: This study is meant to compare the direct and indirect cost of migraine headache care before and after migraine surgery and to evaluate any postoperative changes in patient participation in daily activities. METHODS: Eighty-nine patients enrolled in a migraine surgery clinical trial completed the Migraine-Specific Quality-of-Life Questionnaire, the Migraine Disability Assessment questionnaire, and a financial cost report preoperatively and 5 years postoperatively. RESULTS: Mean follow-up was 63.0 months (range, 56.9 to 72.6 months). Migraine medication expenses were reduced by a median of $1997.26 annually. Median cost reduction for alternative treatment expenses was $450 annually. Patients had a median of three fewer annual primary care visits for the migraine headache treatment, resulting in a median cost reduction of $320 annually. Patients missed a median of 8.5 fewer days of work or childcare annually postoperatively, with a median regained income of $1525. The median total cost spent on migraine headache treatment was $5820 per year preoperatively, declining to $900 per year postoperatively. Total median cost reduction was $3949.70 per year postoperatively. The mean surgical cost was $8378. Significant improvements were demonstrated in all aspects of the Migraine-Specific Quality-of-Life Questionnaire and the Migraine Disability Assessment questionnaire. CONCLUSIONS: Surgical deactivation of migraine trigger sites has proven to be effective for the treatment of severe migraine headache. This study illustrates that the surgical treatment is a cost-effective modality, reducing direct and indirect costs. Patients may also expect improvements in the performance of and increased participation in activities of daily living. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.