[Correlation between referred pain distribution and acupoint sensitization in patients with intestinal diseases].

OBJECTIVE: To observe the correlation between referred pain distribution and acupoint sensitization in patients with intestinal diseases. METHODS: In clinical research, 443 patients from 8 hospitals were recruited, including the outpatients and inpatients of Crohn's disease (n=143), ulcerative colitis (n=108), chronic appendicitis (n=87) and other intestinal diseases (n=105). The site with tenderness on the body surface and the morphological changes of local skin were observed and recorded in the patients. Using a sensory tenderness instrument, the pain threshold at the sensitization point was measured in 60 patients with ulcerative colitis. In animal experiment, SD rats were used and divided into a enteritis group (n=8), in which the enteritis model were established, and a control group (n=3), in which no any intervention was given. After the injection of Evans blue (EB) at caudal vein, the blue exudation points on the body surface were observed and the distribution rule was analyzed statistically. RESULTS: The referred pain on the body surface in the patients with intestinal diseases was mainly located in the lower abdomen (93.9%, 416/443), the lumbar region (70.9%, 314/443) and the lower legs (33.0%, 146/443). The diameter of tenderness region was 1.5 to 2.5 cm. Compared with the region without sensitization, the pain threshold of the sensitization point in the patients with ulcerative colitis was reduced significantly (P<0.001). The referred pain on the body surface in the patients with appendicitis was located in the right lower abdomen (97.7%, 85/87), the waist and back (54.0%, 47/87) and the right lower limbs on the medial side (71.3%, 62/87). The tenderness region was 1 to 2 cm in diameter and was irregular in form. After modeling of enteritis in the rats, the EB exudation points were visible from T12 to L2. CONCLUSION: Intestinal diseases induce referred pain on the body surface where is the same as or adjacent to the location of the spinal segment corresponding to the affected intestinal section. These sensitization regions are related to the locations of acupoints.

Referred Pain Patterns of the Infraspinatus Muscle Elicited by Deep Dry Needling and Manual Palpation.

OBJECTIVES: To identify the most common referred pain (ReP) pattern of the infraspinatus myofascial trigger point (MTrP) and compare its coincidence with the original ReP pattern, to verify whether there are any significant differences by sex and types of technique and to determine the observed signs and symptoms evoked by deep dry needling (DDN) and manual palpation (MPal). DESIGN: A cohort study of patients randomized to two different examination methods (July and August 2016). SETTINGS: Students and staff recruited from Miguel Hernandez University (Southeast Spain). PATIENTS: One hundred thirty-three participants (70.7% women) with shoulder complaints were randomly assigned to either an MPal (n = 67) or DDN group (n = 66). INTERVENTIONS: The same physiotherapist carried out the techniques on all participants, and the same protocol was followed for both the DDN and MPal groups. The physiotherapist did not ask participants about their pain features or other relevant issues. OUTCOME MEASURES: Local twitch response (LTR) and ReP assessed through a visual analogue scale and features of ReP of the infraspinatus muscle. RESULTS: The areas with the highest percentage of ReP were the front (area 3; 27.1%) and back (area 11; 21.1%) of the arm, anterior (area 4; 36.1%) and posterior (area 12; 42.1%) shoulder, and infraspinatus muscle area. DDN proved to be significantly easier than MPal in evoking an LTR (p ≤ 0.001). There were significant differences between sexes in zone 2 (p = 0.041) and no statistically significant differences were found by technique. CONCLUSIONS: The ReP pattern of the infraspinatus muscle coincides with the original pattern described by Travell and Simons, although the neck area should be questioned. The study found no significant differences in the ReP pattern by sex and when comparing MPal with DDN of MTrP of the infraspinatus muscle. DDN proved to be significantly easier than MPal in evoking an LTR.

Iliocostalis Thoracis-Lumborum Myofascial Pain: Reviewing a Subgroup of a Prospective, Randomized, Blinded Trial. A Challenging Diagnosis with Clinical Implications.

BACKGROUND: Pain of myofascial origin is a well-recognized pathology characterized by the presence of two components: referred pain; which is often distant from its source and specific to each muscle, and the trigger point, a localized hyperirritable band present in the affected muscle and able to reproduce the referred pain when stimulated. Myofascial pain (MP) commonly coexists in patients with acute or chronic pain of other etiologies. The uniqueness of the clinical presentation of some MPs and the lack of training of most specialties represent a clinical challenge. Thus, many patients with MPS receive less than optimal management of this condition. OBJECTIVE: Pain at the anterior torso, originating at the posterior torso, can mimic common pathologies that correlate with the same anatomical area such as cardiac and intra-abdominal conditions. These clinical characteristics could be caused by MP of the iliocostalis thoracis-lumborum (ITL) muscle. However, this entity has not been well addressed in the medical literature. In this report we characterize the manifestations, diagnosis, and clinical implications of ITL MP. STUDY DESIGN: Observational assessment. SETTING: Two university-based academic emergency medicine departments (ED) in an urban setting in the United States. METHODS: A convenience sample of 43 patients who presented to the ED with pain at the anterior aspect of the torso (chest, abdomen, or pelvis) and clinical evidence of MP originated in the ITL muscle.Of a clinical trial of patients with MP, we describe a subgroup of patients with MP of the ITL which was clinically evident by the presence of a trigger point (TP) in its ability to reproduce the referred pain present at the anterior aspect of the torso. Patients received a TP injection. In this trial we intend to demonstrate that TP injections using particulate steroids mixed with a local are no more effective than saline alone to treat MP. The primary outcome was pain control (decrease in intensity of 50% or more below baseline numeric pain rating). A follow-up telephone interview was performed by third-party abstractors. RESULTS: Forty-three patients presented with pain of the anterior torso and ipsilateral back, both correlating with the level of the TP of the ITL muscle. The pain had been present from 2 days to 7 years. The most common locations of pain were the right-lower quadrant and the left side of the chest. In many of them a pattern of missed diagnosis was evident despite extensive workups and consultations. Only 17 patients were able to identify the precipitating event; the most common was coughing. Two weeks after TP injection, all patients still had satisfactory pain control. After treatment, no missed pathology or returns to the ED were reported. LIMITATIONS: This descriptive portion of the ongoing study does not affect the integrity of the trial itself but could be subject to the introduction of subject selection and selective reporting bias. Similarly, this convenience sample does not establish the incidence of this pathology and challenges the external validity to other clinical settings. CONCLUSIONS: Anterior torso pain often resulted in extensive workups before ITL myofascial pain was diagnosed. TP injections were diagnostic and therapeutic of ITL myofascial pain.

[Pseudo-radicular referred leg pain]. / Pseudoradikulärer/übertragener Beinschmerz.

Pseudo-radicular leg pain as initially described by Bruegger more than 55 years ago was at that time a genius explanation for so many non-radicular pain syndromes that needed not any kind of surgical intervention but in first line a manual treatment or a treatment by therapeutic local anesthetics. Today we describe this pain as a "referred pain" originating from other anatomic structures that may occur during the development of chronic pain. Nevertheless this pain is found in many patients and it still seems to be a big problem for many physicians and surgeons. Imaging does not help either. The history and the clinical symptoms, the examinations, the chain reactions in the motor system as well as the treatment options from the point of view of manual medicine are described.

Trigger point-related sympathetic nerve activity in chronic sciatic leg pain: a case study.

Sciatica has classically been associated with irritation of the sciatic nerve by the vertebral disc and consequent inflammation. Some authors suggest that active trigger points in the gluteus minimus muscle can refer pain in similar way to sciatica. Trigger point diagnosis is based on Travel and Simons criteria, but referred pain and twitch response are significant confirmatory signs of the diagnostic criteria. Although vasoconstriction in the area of a latent trigger point has been demonstrated, the vasomotor reaction of active trigger points has not been examined. We report the case of a 22-year-old Caucasian European man who presented with a 3-year history of chronic sciatic-type leg pain. In the third year of symptoms, coexistent myofascial pain syndrome was diagnosed. Acupuncture needle stimulation of active trigger points under infrared thermovisual camera showed a sudden short-term vasodilatation (an autonomic phenomenon) in the area of referred pain. The vasodilatation spread from 0.2 to 171.9 cm(2) and then gradually decreased. After needling, increases in average and maximum skin temperature were seen as follows: for the thigh, changes were +2.6°C (average) and +3.6°C (maximum); for the calf, changes were +0.9°C (average) and +1.4°C (maximum). It is not yet known whether the vasodilatation observed was evoked exclusively by dry needling of active trigger points. The complex condition of the patient suggests that other variables might have influenced the infrared thermovision camera results. We suggest that it is important to check if vasodilatation in the area of referred pain occurs in all patients with active trigger points.

Myofascial trigger points, pain, disability, and sleep quality in individuals with mechanical neck pain.

OBJECTIVE: The purpose of this study was to investigate the presence of active myofascial trigger points (MTrPs) in a greater number of muscles than previous studies and the relation between the presence of MTrPs, the intensity of pain, disability, and sleep quality in mechanical neck pain. METHODS: Fifteen patients with mechanical neck pain (80% women) and 12 comparable controls participated. Myofascial trigger points were bilaterally explored in the upper trapezius, splenius capitis, semispinalis capitis, sternocleidomastoid, levator scapulae, and scalene muscles in a blinded design. Myofascial trigger points were considered active if the subject recognized the elicited referred pain as a familiar symptom. Myofascial trigger points were considered latent if the elicited referred pain was not recognized as a symptom. Pain was collected with a numerical pain rate scale (0-10); disability was assessed with Neck Disability Index; and sleep quality, with the Pittsburgh Sleep Quality Index. RESULTS: Patients exhibited a greater disability and worse sleep quality than controls (P < .001). The Pittsburgh Sleep Quality Index score was associated with the worst intensity of pain (r = 0.589; P = .021) and disability (r = 0.552; P = .033). Patients showed a greater (P = .002) number of active MTrPs (mean, 2 ± 2) and similar number (P = .505) of latent MTrPs (1.6 ± 1.4) than controls (latent MTrPs, 1.3 ± 1.4). No significant association between the number of latent or active MTrPs and pain, disability, or sleep quality was found. CONCLUSIONS: The referred pain elicited by active MTrPs in the neck and shoulder muscles contributed to symptoms in mechanical neck pain. Patients exhibited higher disability and worse sleep quality than controls. Sleep quality was associated with pain intensity and disability. No association between active MTrPs and the intensity of pain, disability, or sleep quality was found.

Effect of ischemic pressure using a Backnobber II device on discomfort associated with myofascial trigger points.

OBJECTIVE: The purpose of this study was to assess the effectiveness of ischemic pressure on myofascial trigger point (MTrP) sensitivity. DESIGN: Randomized, controlled study with the researcher assessing MTrP sensitivity blinded to the intervention. PARTICIPANTS: Twenty-eight people with two MTrPs in the upper back musculature. INTERVENTION: The sensitivity of two MTrPs in the upper back was assessed with a JTECH algometer. One of the two MTrPs was randomly selected for treatment with a Backnobber II, while the other served as a control. OUTCOME MEASURES: Pre- and post-test pressure-pain thresholds of the MTrPs RESULTS: There was a significant difference between the pre- and post-test sensitivities of the treated and non-treated MTrPs (p=0.04). CONCLUSIONS: The results of this study confirm that the protocol of six repetitions of 30-s ischemic compression with the Backnobber II rendered every other day for a week was effective in reducing MTrP irritability.

Diagnosis and management of non-dental orofacial pain.

UNLABELLED: Careful history-taking improves diagnosis of non-dental orofacial pain, a not uncommon group of conditions. Accurate diagnosis of conditions such as chronic idiopathic facial pain, temporomandibular disorders, burning mouth syndrome and trigeminal neuralgia is essential if inappropriate dental treatment is to be avoided. There are few investigations to help in the diagnostic process and many of these patients have other forms of chronic pain. All the conditions are best treated using a holistic approach. Drugs, such as tricyclic antidepressants and anticonvulsants, are often effective and surgery can be highly successfully in trigeminal neuralgia. Patient education is paramount. CLINICAL RELEVANCE: Although the majority of pain seen in general dental practice is dental in origin, chronic non-dental orofacial pain must be recognized as its management is entirely different.