Effects of exercise-based interventions on inflammatory markers in patients with fibromyalgia: A systematic review and meta-analysis.

OBJECTIVES: The aim of the present review was (1) to determine the effects of exercise based-interventions (EBIs) on pro-inflammatory and anti-inflammatory biomarkers in patients with fibromyalgia (FM), and (2) to determine the most effective type (acute or maintained) and modality (aerobic, resistance, etc.). METHODS: A systematic search was conducted in various electronic databases to identify all the relevant studies: Medline (PubMed), PEDro, EBSCO and Google Scholar. Clinical trials assessing the effects of EBIs in patients with FM were selected. Methodological quality was evaluated by two independent investigators using the Cochrane Risk of Bias Tool. Qualitative analysis was based on the classification of the results into levels of evidence according to GRADE. RESULTS: Eleven studies were included. The meta-analysis showed a statistically significant decrease in proinflammatory biomarkers by EBIs with a large clinical effect in 19 comparisons (SMD: 1.74; 95 % CI: 0.85-2.62; p < 0.05), especially for IL8. The certainty of the evidence was low. The meta-analysis showed no statistically significant increase in anti-inflammatory biomarkers (IL10) by EBIs in 6 comparisons and very low certainty of evidence. Evidence was found for acute and maintained effects of exercise, with aerobic and aquatic exercise modalities showing better improvements than resistance exercise. CONCLUSIONS: EBIs are effective in inducing an immunomodulatory response in FM, characterized by decreased pro-inflammatory signaling. However, there was no evidence of an increase in anti-inflammatory biomarkers. These results should be interpreted with caution due to low certainty of evidence.

The Area of Pressure-Induced Referred Pain Is Dependent on the Intensity of the Suprathreshold Stimulus: An Explorative Study.

OBJECTIVE: To investigate the pain referral area (number of pixels) and extent (vector length) as elicited from increasing intensities of pressure-induced pain at the shoulder. DESIGN: Cross-sectional design. SETTING: Clinical laboratory setting. PARTICIPANTS: Twenty-two healthy men and women participated in two experimental sessions. METHODS: Delayed onset of muscle soreness (DOMS) was induced in the dominant shoulder and assessed 24 hours later. Participants rated the level of DOMS on a 6-point Likert scale. Four different intensities (pressure pain threshold [PPT]+20%, PPT+30%, PPT+40%, and PPT+50%) were applied to the infraspinatus in a randomized, balanced fashion for 60 seconds from low to high intensity or vice versa. The resulting location, area, and extent of referred pain as drawn by the participants on a digital body chart were extracted and expressed in pixels. The extent of pain was defined as the vector length extending from the ipsilateral earlobe to the most distal location of the pain. RESULTS: The referred pain area from PPT+20% was smaller than PPT+30%, PPT+40%, and PPT+50%. The extent of referred pain did not differ between the pressure pain intensities. CONCLUSIONS: Pressure intensity at PPT+30%, but no more, produces the greatest referred pain area as compared with the traditional pressure intensity of PPT+20%. Thus, the intensity of PPT+30% may be ideal for exploring the mechanisms of referred pain. The extent of the pain represents an independent expression of the intensity of the provoking stimulus and may be more closely related to the location of the stimulus.

Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis.

OBJECTIVE: To summarize the cervical physical examination characteristics in subjects with chronic primary headache and compare those with a healthy population and a population with episodic primary headache. DESIGN: Systematic review and meta-analysis. SUBJECTS: Humans ≥18 years old. At least one of the study groups should be constituted by subjects diagnosed with one of the chronic primary headache subtypes according to the International Classification of Headache Disorders, 3rd Edition. COMPARISON: Neck physical examination outcomes of subjects with chronic primary headache compared with a healthy population or subjects with episodic primary headache. OUTCOMES: Forward head posture (FHP), cervical range of movement, motor control, neck muscle activity, and reproduction and resolution of symptoms. METHODS: Two reviewers assessed independently the MEDLINE, EMBASE, WOS, MEDES, PEDro, and CINAHL databases to select observational studies. First, both implemented an agreement for a search strategy. Then, they screened independently for duplicates, titles, abstracts, and full-text information. A meta-analysis was conducted to compare measures between groups. RESULTS: Twelve studies (N = 1,083) with moderate quality (mean ± SD = 7.75 ± 1.48 on the Newcastle Ottawa Scale) were selected for the qualitative analysis. The meta-analysis showed that patients with chronic primary headache presented greater forward head posture than asymptomatic participants (N = 275, Hg = 0.68, 95% CI = 0.25-1.1, Z = 3.14, P < 0.01) and patients with episodic primary headache (N = 268, Hg = 0.39, 95% CI = 0.13-0.65, Z = 2.98, P < 0.01). CONCLUSIONS: There is moderate to strong evidence that patients with chronic primary headache present greater FHP than asymptomatic individuals and moderate evidence that patients with chronic primary headache present greater forward head posture than those with episodic primary headache.

Influence of the Generation of Motor Mental Images on Physiotherapy Treatment in Patients with Chronic Low Back Pain.

BACKGROUND: Patients with nonspecific chronic low back pain (NCLBP) have greater difficulty generating kinesthetic and visual motor imagery. OBJECTIVES: The main aim of this study was to determine whether the ability to generate mental motor imagery (MIab) influences psychological, motor, and disability variables in patients with NCLBP. The secondary aim was to determine whether an approach based on therapeutic exercise (TE) and therapeutic education (TEd) could improve the MIab in those patients with less ability to perform it. STUDY DESIGN: Cross-sectional and quasiexperimental study. SETTING: Physical Therapy Unit of primary health care center in Madrid, Spain. METHODS: A total of 68 patients were divided into 2 groups according to a greater (n = 34) or lesser (n = 34) MIab. Treatment was based on TEd and TE for the group with less ability to generate kinesthetic and visual motor imagery. The outcome measures were imagery requested time, self-efficacy, disability, pain intensity, lumbar strength, psychological variables, and MIab. RESULTS: The group with lesser MIab showed lower levels of self-efficacy (P = 0.04; d, -0.47) and lower levels of lumbar strength and extension strength (P = 0.04; d, -0.46 and P = 0.02; d, -0.52, respectively). After the intervention with TE and TEd, MIab (both kinesthetic and visual) improved significantly, with a moderate to large effect size (P <= 0.01; d, -0.80 and P <= 0.01; d, -0.76, respectively), as did pain intensity, lumbar strength, disability, and psychological variables (P < 0.05), but not levels of self-efficacy (P > 0.05). Based on the results, the patients with NCLBP with lesser MIab achieved lower levels of self-efficacy and lower strength levels. LIMITATIONS: The results of this study should be interpreted with caution because of its quasiexperimental design and a bias selection. CONCLUSIONS: A clinical TE approach, coupled with a TEd program, resulted in significant improvement in MIab (both kinesthetic and visual), reduced pain intensity, increased lumbar strength, reduced disability, and improved psychological variables, but it did not significantly improve self-efficacy levels in the patients with NCLBP. KEY WORDS: Chronic low back pain, motor imagery, disability, lumbar strength.

Temporomandibular disorders: improving outcomes using a multidisciplinary approach.

Patients with temporomandibular disorders (TMD) can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental. There are various health professions that have competence in the treatment of TMD, however, although in the most complex cases should be treated simultaneously, still too many patients receive unique treatments and only from one point of view. This review exposes the treatments available from a clinical-scientific perspective and also emphasizes the importance of working in specialized units with those professionals who have competencies on the different conditions that may occur.

Widespread mechanical pain hypersensitivity in patients with chronic migraine and temporomandibular disorders: relationship and correlation between psychological and sensorimotor variables.

OBJECTIVE: This study aimed to assess mechanical hyperalgesia in the trigeminal and extra-trigeminal regions in patients with chronic migraine (CM) and temporomandibular disorders (TMD) in comparison to asymptomatic subjects and to determine the association between sensorimotor variables and psychological and disability variables and evaluate the prediction of a sensorimotor variables though psychological and disability variables in patients with CM and TMD. MATERIAL AND METHODS: A total of 52 subjects with concomitant CM and TMD and 30 asymptomatic subjects were included in the study. The pressure pain threshold (PPT), maximal mouth opening (MMO) and a series of self-reported factors were compared. RESULTS: There were 52 CM and TMD (92.3% women and 7.7% men; age = 46.2 ± 9.5) and 30 asymptomatic subjects (80% women and 20% men; age = 47.4 ± 10). Differences were found between patients with CM and TMD and asymptomatic participants (p < .01) when comparing the PPTs in the trigeminal and extra-trigeminal regions. The PPT for the trigeminal region was predicted by depressive symptoms (variance of 18%) as well as disability and craniofacial pain (variance of 20%). The extra-trigeminal region PPT was predicted by depressive symptoms (variance of 10%), and pain-free MMO was predicted by disability and craniofacial pain (variance of 24%). CONCLUSIONS: This study suggests that patients with CM and TMD present with generalized mechanical hyperalgesia. In addition, an association between sensorimotor, psychological and disability variables was observed.

Effects of a Physical Therapy Protocol in Patients with Chronic Migraine and Temporomandibular Disorders: A Randomized, Single-Blinded, Clinical Trial.

AIMS: To investigate the effects of adding orofacial treatment to cervical physical therapy in patients with chronic migraine and temporomandibular disorders (TMD). METHODS: A total of 45 participants with chronic migraine and TMD aged 18 to 65 years were randomized into two groups: a cervical group (CG) and a cervical and orofacial group (COG). Both groups continued their medication regimens for migraine treatment and received physical therapy. The CG received physical therapy only in the cervical region, and the COG received physical therapy in both the cervical and orofacial regions. Both groups received six sessions of treatment that consisted of manual therapy and therapeutic exercise in the cervical region or the cervical and orofacial regions. Scores on the Craniofacial Pain and Disability Inventory (CF-PDI) and the Headache Impact Test (HIT-6) were primary outcome variables, and the secondary outcome variables were scores on the Tampa Scale for Kinesiophobia (TSK-11), pain intensity measured on a visual analog scale (VAS), pressure pain thresholds (PPTs) in the temporal, masseter (2 points, M1 and M2) and extratrigeminal (wrist) regions, and maximal mouth opening (MMO). Data were recorded at baseline, posttreatment, and after 12 weeks of follow-up. The α level was set at .05 for all tests and two-way repeated-measures analysis of variance (ANOVA) for within- and between-group interactions. RESULTS: There were 22 CG participants (13.6% men and 86.4% women) and 23 COG participants (13% men and 87% women). The ANOVA analysis revealed statistically significant differences for group × time interaction in CF-PDI, HIT-6 in the last follow-up, pain intensity, PPTs in the trigeminal region, and MMO (P < .05), with a medium-large magnitude of effect. No statistically significant differences were found in the PPTs of the extratrigeminal region or in the TSK-11 (P > .05). CONCLUSION: Both groups reported a significant improvement in CF-PDI, HIT-6, and pain intensity. Cervical and orofacial treatment was more effective than cervical treatment alone for increasing PPTs in the trigeminal region and producing pain-free MMO. Physical therapy alone was not effective for increasing the PPTs in the extratrigeminal region (wrist) or decreasing the level of TSK-11.