The role of voltage-gated calcium channel α2δ-1 in the occurrence and development in myofascial orofacial pain.

Patients who suffer from myofascial orofacial pain could affect their quality of life deeply. The pathogenesis of pain is still unclear. Our objective was to assess Whether Voltage-gated calcium channel α2δ-1(Cavα2δ-1) is related to myofascial orofacial pain. Rats were divided into the masseter tendon ligation group and the sham group. Compared with the sham group, the mechanical pain threshold of the masseter tendon ligation group was reduced on the 4th, 7th, 10th and 14th day after operation(P < 0.05). On the 14th day after operation, Cavα2δ-1 mRNA expression levels in trigeminal ganglion (TG) and the trigeminal spinal subnucleus caudalis and C1-C2 spinal cervical dorsal horn (Vc/C2) of the masseter tendon ligation group were increased (PTG=0.021, PVc/C2=0.012). Rats were divided into three groups. On the 4th day after ligating the superficial tendon of the left masseter muscle of the rats, 10 ul Cavα2δ-1 antisense oligonucleotide, 10 ul Cavα2δ-1 mismatched oligonucleotides and 10 ul normal saline was separately injected into the left masseter muscle of rats in Cavα2δ-1 antisense oligonucleotide group, Cavα2δ-1 mismatched oligonucleotides group and normal saline control group twice a day for 4 days. The mechanical pain threshold of the Cavα2δ-1 antisense oligonucleotides group was higher than Cavα2δ-1 mismatched oligonucleotides group on the 7th and 10th day after operation (P < 0.01). After PC12 cells were treated with lipopolysaccharide, Cavα2δ-1 mRNA expression level increased (P < 0.001). Cavα2δ-1 may be involved in the occurrence and development in myofascial orofacial pain.

Pain and daily interference among reproductive-age women with myofascial pelvic pain: Serial mediation roles of kinesiophobia, self-efficacy and pain catastrophizing.

BACKGROUND: Myofascial pelvic pain (MFPP), which is identified by tender points in the pelvic floor musculature, is a prevalent source of chronic pelvic pain in women. It may lead to physical and mental exhaustion, reproductive concerns, and coping difficulties in daily life and work than the disease itself. Pain-related cognitive processes can affect pain relief and quality of life. Kinesiophobia, self-efficacy and pain catastrophizing are frequently treated as mediators between pain and its related consequences. Greater kinesiophobia and pain catastrophizing have been shown to be associated with adverse functional outcomes, while higher self-efficacy has been related with improved quality of life. Regarding MFPP in females of childbearing age, it remains unclear whether the effects of kinesiophobia, self-efficacy and pain catastrophizing on daily interference are direct or indirect; the influence on each variable is, therefore, not entirely evident. AIM: The present study aimed to evaluate the relationship between pain and daily interference in reproductive-age women with MFPP through kinesiophobia, self-efficacy and pain catastrophizing, as well as to identify areas for future investigation and intervention based on the data collected from this population. METHODS: This is a multi-center cross-sectional study. The study was conducted from November 15, 2022 to November 10, 2023, 202 reproductive-age women with MFPP were recruited from 14 hospitals in ten provinces of China. The demographic variables, Brief Pain Inventory, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, and Pain Catastrophizing Scale were used to measure the participants' related information. The data was described and analyzed using Descriptive analyses, Pearson correlation analysis, and Serial mediation modeling. RESULTS: Pain not only had a direct positive impact (B = 0.575; SE = 0.081; 95%CI: LL = 0.415, UL = 0.735) on daily interference, but also had an indirect impact on daily interference through the independent mediating role of pain catastrophizing (B = 0.088; SE = 0.028; 95%CI: LL = 0.038, UL = 0.148), the chain mediating of kinesiophobia and catastrophizing (B = 0.057; SE = 0.019; 95%CI: LL = 0.024, UL = 0.098), and the four-stage serial mediating of kinesiophobia, self-efficacy and catastrophizing (B = 0.013; SE = 0.006; 95%CI: LL = 0.003, UL = 0.027). The proposed serial mediation model showed a good fit with the collected data. CONCLUSION: The findings illustrate the significance of addressing pain catastrophizing and kinesiophobia (especially catastrophizing), and increasing self-efficacy in pain therapy, and suggest that functional recovery be integrated into pain therapy for reproductive-age women suffering from MFPP.

The difference in the upper trapezius deep fascia slides between individuals with and without myofascial pain syndrome: A case-control study.

INTRODUCTION: MPS is a chronic disorder caused by myofascial trigger points, leading to pain and limited neck movements due to impacted fascia. Studies have reported reduced fascia slides in chronic low back pain, but limited fascia slides in MPS patients are still unreported. AIM: We determined differences in upper trapezius' deep fascia slides between MPS and non-MPS participants. METHODS: Between January-August 2019, participants from diverse work sectors were recruited in Manila. An expert physiotherapist diagnosed MPS, while non-MPS participants performed full painless cervical movements. Participants underwent upper trapezius deep fascia scans on both shoulders while performing six cervical movements. An HS1 Konica Minolta ultrasound recorded the data. Two blinded physiotherapists used Tracker 5.0 © 2018 to analyze videos and quantify deep fascia slides by measuring the distance between two x-axis points. The Multivariate analysis of variance (MANOVA) assessed deep fascia slide differences in six active cervical movements. Pillai's Trace, with a range of 0-1 and a p-value of <0.05, was set. Effect sizes in individuals with and without MPS were calculated using Hedges' g and Cohen's d. RESULTS: Of the 327 participants (136 non-MPS, 191 MPS), 101 MPS participants had shoulder pain for <1 year and 103 experienced unilateral pain. The study examined 3800 ultrasound videos but found no significant difference in deep fascia slides across cervical movements between MPS and non-MPS groups (Pillai's Trace = 0.004, p = 0.94). Minor differences in deep fascia displacement were observed, with small effect sizes (g = 0.02-0.08). CONCLUSION: A limited deep fascia slide does not characterize MPS participants from non-MPS participants.

Association between myofascial trigger point therapy and conditioned pain modulation.

INTRODUCTION: Myofascial trigger point therapy (MTrP) is a widely used therapeutic approach, although the underlying mechanisms remain unclear. Mechanisms discussed include peripheral involvement of muscles as well as central pain modulating processes such as the conditioned pain modulation (CPM). The aim of this study was to investigate whether the analgesic response of MTrP and the analgesic response of CPM correlate in asymptomatic participants in order to identify shared underlying mechanisms of MTrP and CPM. METHOD: Both, CPM and MTrP protocols consisted of heat-based test stimuli (heat pain thresholds before and after the intervention) and pressure-based (conditioning) stimuli. Asymptomatic participants (n = 94) were randomly assigned to receive either mild, intense or no pressure stimuli (between-group design) to both the fingernail and the MTrP of the infraspinatus muscle (within-group design). Pressure stimuli at both locations (fingernail, MTrP) were applied with a pressure algometer for 120 s and continuously adjusted to maintain a constant pain intensity of mild or intense pain. All thermal stimuli were applied on the lower leg with a thermal stimulator. RESULTS: A significant correlation was shown between the analgesic effect of CPM and MTrP therapy for mild (r = 0.53, p = 0.002) and intensive stimuli (r = 0.73, p < 0.001). 17.3% of the variance of the MTrP effect were explained by CPM after mild stimulation, and 47.1% after intense stimulation. Pain-related characteristics did not explain the variance within the analgesic response using a regression analysis. CONCLUSIONS: Between the analgesic responses following MTrP and CPM paradigms, a moderate to strong correlation was observed, suggesting shared underlying mechanisms.

Efficacy of capacitive-resistive therapy on the treatment of myofascial pain - A randomized control trial.

BACKGROUND: Myofascial pain syndrome is a painful musculoskeletal condition with muscle spasm, referred pain, stiffness, restricted range of motion. Capacitive-resistive diathermy heats deep tissues by transferring energy through radiofrequency waves. Although this modality is used to treat various musculoskeletal disorders, there is no specific data on myofascial trigger points. Thus, we aimed to evaluate the effectiveness of capacitive-resistive diathermy on the myofascial trigger points. METHODS: Thirty-six volunteers with active myofascial trigger points were included. Patients were randomly and equally allocated into two groups. Group-1 is the capacitive-resistive diathermy treatment group; Group-2 is the placebo capacitive-resistive diathermy (PG). Visual analog scale (VAS), pain pressure threshold (PPT), neck disability index (NDI), neck range of motion (nROM), Short form-36 (SF-36) were used as outcomes before and after the intervention. RESULTS: In both groups, VAS, PPT, NDI score significantly improved within the groups (p < 0.05). The CRG showed a statistically significant improvement in nROM for flexion, extension, and rotation (p < 0.05). However, ROM increase in CRG is not superior to PG (p > 0.05). CONCLUSIONS: There was no significant difference between the two groups. We thought positive results in the PG might attributed to doing exercise. As a result, capacitive-resistive diathermy is not superior to exercise, but can be used as an adjuvant modality in myofascial trigger points treatment.

Myofascial trigger point (MTrP) size and elasticity properties can be used to differentiate characteristics of MTrPs in lower back skeletal muscle.

Myofascial trigger points (MTrPs) are localized contraction knots that develop after muscle overuse or an acute trauma. Significant work has been done to understand, diagnose, and treat MTrPs in order to improve patients suffering from their effects. However, effective non-invasive diagnostic tools are still a missing gap in both understanding and treating MTrPs. Effective treatments for patients suffering from MTrP mediated pain require a means to measure MTrP properties quantitatively and diagnostically both prior to and during intervention. Further, quantitative measurements of MTrPs are often limited by the availability of equipment and training. Here we develop ultrasound (US) based diagnostic metrics that can be used to distinguish the biophysical properties of MTrPs, and show how those metrics can be used by clinicians during patient diagnosis and treatment. We highlight the advantages and limitations of previous US-based approaches that utilize elasticity theory. To overcome these previous limitations, we use a hierarchical approach to distinguish MTrP properties by patients' reported pain and clinician measured palpation. We show how US-based measurements can characterize MTrPs with this approach. We demonstrate that MTrPs tend to be smaller, stiffer, and deeper in the muscle tissue for patients with pain compared to patients without pain. We provide evidence that more than one MTrP within a single US-image field increases the stiffness of neighboring MTrPs. Finally, we highlight a combination of metrics (depth, thickness, and stiffness) that can be used by clinicians to evaluate individual MTrPs in combination with standard clinical assessments.

Dynamics of disability and pain indicators under the influence of physical therapy for adhesives capsulitis and myofascial pain syndrome.

OBJECTIVE: Aim: To compare the effectiveness of end-range mobilization and therapeutic exercises, used in combination with ischemic compression, on disability and pain indicators among patients with adhesive capsulitis of the shoulder joint and thoracic myofascial pain syndrome. PATIENTS AND METHODS: Materials and Methods: The study involved 68 patients. Goniometry of the shoulder joint, assessment of pain in myofascial trigger points, and the Shoulder Pain and Disability Index questionnaire were used before and after physical therapy. The duration of physical therapy comprised 3 weeks. Physical therapy of the first group of patients consisted of end-range mobilization and ischemic compression. Patients of the second group performed therapeutic exercises and ischemic compression. RESULTS: Results: Both groups demonstrated positive dynamics of shoulder joint mobility, Shoulder Pain and Disability Index and pain in trigger points. However, the final results of the studied indicators were better in the first group of patients. CONCLUSION: Conclusions: Physical therapy based on the combination of end-range mobilization and ischemic compression had a more positive impact on disability and pain indicators for adhesive capsulitis of the shoulder joint and myofascial pain syndrome as compared to the combination of therapeutic exercises and ischemic compression.

COMPARISON THE EFFICACY OF DRY NEEDLING AND ISCHEMIC COMPRESSION METHODS IN MIYOFASCIAL PAIN SYNDROME: A RANDOMIZED TRIAL.

Myofascial pain syndrome (MPS) is the most common in the musculoskeletal disease. Dry needling techniques and ischemic compression are the most common applications. We aimed to compare the efficacy of dry needling and ischemic compression methods on pain, cervical range of motion and disability in myofascial pain syndrome. This is a randomized, controlled study. 98 patients with MPS were randomly assigned into three groups. Group1 received dry needling (n=33), group 2 (n=33) received ischemic compression and group 3 (n=32) received combined with dry needling and ischemic compression inventions. Additionally, all patients were given neck exercise programs including isotonic, isometric, and stretching. The severity of the pain was measured by visual analog scale (VAS). The pressure pain threshold (PPT) and cervical range of motion (ROM) were also recorded. Disability was assessed by the Neck Pain Disability Scale. All assessments were performed before the treatment and one month and three months after the treatment. There were statistically significant improvements in VAS, PPT, cervical ROM, and disability scores after one and three months in all groups compared to pre-treatment results (p<0.05). After three months of follow-up, statistically significant differences were observed in all parameters between the groups (p<0.05) except cervical ROM (p>0.05). Myofascial pain syndrome in patients with ischemic compression and dry needling effective treatment methods are shown separately in our study to be more effective when used together.

Is adding dry needling to a standard care protocol beneficial in patients with chronic neck pain? A randomized placebo-controlled trial.

PURPOSE: To evaluate the short-term effects of adding a dry needling therapy to a standard care protocol based on education, exercise and electrotherapy, compared to a sham procedure and to a standard care protocol in isolation in patients with chronic neck pain. MATERIAL AND METHODS: A randomized placebo-controlled trial was performed. The participants in the dry needling group received a standard care protocol based on patient education, therapeutic exercise and electrotherapy, as well as two sessions of dry needling in the upper trapezius, levator scapulae, and/or sternocleidomastoid muscles. The participants in the sham dry needling group received the same standard care protocol and two sessions of sham dry needling. The participants in the control group received the same standard care protocol. The outcomes measured were pain intensity, pressure pain threshold, neck disability, range of movement, activation of deep cervical flexor muscles, kinesiophobia, pain catastrophizing, anxiety, and depression. RESULTS: No significant group by time interactions were found for any of the outcome variables except for lower cervical spine range of movement (F = 3.79; p = 0.030). CONCLUSION: The addition of two sessions of dry needling in the superficial neck muscles to a standard protocol did not yield superior results compared to either the standard care alone or the standard care plus sham dry needling in patients with chronic neck pain in any outcome except for cervical range of movement.

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.

Botulinum toxin-A effects on pain, somatosensory and psychosocial features of patients with refractory masticatory myofascial pain: a randomized double-blind clinical trial.

The antinociceptive effect of BoNT-A have been well documented in animal studies; however, results of few but well-designed randomized placebo-controlled clinical trials about BoNT-A efficacy in masticatory myofascial pain (MFP) are inconsistent. Therefore, the present randomized, double-blind, placebo-controlled clinical trial evaluated the efficacy of BoNT-A in patients with refractory MFP. Twenty-eight patients with pain reduction of less than 30% despite conservative treatment and with an average pain intensity of > 50 mm on the visual analogue scale (VAS) participated. Patients were randomly assigned to receive a total of 80 U of BoNT-A or saline solution (SS) injected into the masseter and anterior temporalis muscles. Pain intensity (VAS), quantitative sensory testing (QST), conditioned pain modulation (CPM), and psychosocial status were examined. Follow-up was performed at 1 and 6 months. For repeated-measure comparisons between evaluation times, Friedman test with Bonferroni correction was used for pain and somatosensory variables and the Wilcoxon test for the psychosocial variables. The Mann-Whitney test was used for all comparisons between groups. The BoNT-A group had a significant decrease in pain intensity at follow-ups compared with the SS group (p < 0.001). QST assessment revealed higher pressure pain threshold values in the masseter muscle for BoNT-A group compared to SS (p < 0.03) at all follow-ups. No differences were found for mechanical pain threshold and wind-up ratio values (p > 0.05) in the entire study. The BoNT-A group presented the most efficient CPM effect (p < 0.03) only at the 1 month follow-up in the masseter muscle. There was a significant time effect for BoNT-A in all psychosocial variables (p < 0.05) and a drug effect in the Central Sensitization Inventory (p < 0.01), Pittsburgh Sleep Quality Index (p < 0.004), and Healthy Survey 36 (p < 0.05) at 6 months follow-up. The study demonstrates that a single injection-session of BoNT-A has positive effects on the hall pain spectrum of patients with refractory masticatory myofascial pain.

Validation of Distinct Bladder Pain Phenotypes Utilizing the MAPP Research Network Cohort.

INTRODUCTION AND HYPOTHESIS: As interstitial cystitis/bladder pain syndrome (IC/BPS) likely represents multiple pathophysiologies, we sought to validate three clinical phenotypes of IC/BPS patients in a large, multi-center cohort using unsupervised machine learning (ML) analysis. METHODS: Using the female Genitourinary Pain Index and O'Leary-Sant Indices, k-means unsupervised clustering was utilized to define symptomatic phenotypes in 130 premenopausal IC/BPS participants recruited through the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) research network. Patient-reported symptoms were directly compared between MAPP ML-derived phenotypic clusters to previously defined phenotypes from a single center (SC) cohort. RESULTS: Unsupervised ML categorized IC/BPS participants into three phenotypes with distinct pain and urinary symptom patterns: myofascial pain, non-urologic pelvic pain, and bladder-specific pain. Defining characteristics included presence of myofascial pain or trigger points on examination for myofascial pain patients (p = 0.003) and bladder pain/burning for bladder-specific pain patients (p < 0.001). The three phenotypes were derived using only 11 features (fGUPI subscales and ICSI/ICPI items), in contrast to 49 items required previously. Despite substantial reduction in classification features, unsupervised ML independently generated similar symptomatic clusters in the MAPP cohort with equivalent symptomatic patterns and physical examination findings as the SC cohort. CONCLUSIONS: The reproducible identification of IC/BPS phenotypes, distinguishing bladder-specific pain from myofascial and genital pain, using independent ML analysis of a multicenter database suggests these phenotypes reflect true pathophysiologic differences in IC/BPS patients.

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).

The effectiveness of deep tissue massage on pain, trigger point, disability, range of motion and quality of life in individuals with myofascial pain syndrome.

PURPOSE: This study aims to examine the effect of deep tissue massage (DTM) on the myofascial trigger point (MTrP) number, neck range of motion (ROM), pain, disability and quality of life in patients with Myofacial pain syndrome (MPS). METHODS: The study involved patients with MPS between the ages of 20-57. The patients were randomly divided into two groups: the control group (n = 40) and the study group (n = 40). Transcutaneous Electrical Neuromuscular Stimulation (TENS), hotpack and ultrasound were applied to 40 patients in the control group. The study group was also administered DTM for 12 sessions in addition to TENS, hotpack and ultrasound applications. Neck pain and disability scale (NPDS) for a neck disability, universal goniometer for neck ROM, MTrP count using manual palpation, Short Form 36 (SF-36) for quality of life and severity of neck pain were evaluated using a visual analog scale (VAS). All patients were evaluated before and after treatment. RESULTS: It was found that the DTM group has statistically more improvement than the control group for VAS, NPDS and SF-36. Moreover, although there was a significant improvement in favour of the study group for extension, lateral flexion, right rotation and left rotation in the neck ROM, there was no significant difference in flexion measurements between the study and control group. CONCLUSION: In addition to the traditional rehabilitation program, DTM is effective on neck ROM, pain, disability and quality of life. Therefore, DTM treatment is a safe and inexpensive treatment method that can be applied in patients with MPS.

The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients.

OBJECTIVES: Post cholecystectomy pain syndrome can cause significant distress, impairs quality of life and exacerbations often result in emergency visits. Poorly controlled postoperative pain is a recognized cause of persistent postsurgical pain. Abdominal myofascial pain syndrome is an underdiagnosed cause of persistent pain in this cohort. The objective was to estimate the incidence of poorly controlled postoperative pain in the first 48 h after surgery and the likelihood of developing persistent pain at 12 months. METHODS: The patients undergoing laparoscopic cholecystectomy at a tertiary unit were consented for participation in a prospective service evaluation. A telephone review was performed at three, six and twelve months after surgery. Incidence of poorly controlled pain in the first 48 h after surgery was assessed. Patients with persistent pain were referred to the pain clinic. RESULTS: Over a six-month period, 200 patients were assessed. Eleven patients were excluded (5.5 %). Twelve patients were lost to follow-up (6.6 %, 12/189). Patient satisfaction with acute postoperative pain management was low in 40 % (76/189). Poorly controlled postoperative pain was reported by 36 % (68/189) of patients. Incidence of persistent pain was 29 % (54/189) at 12 months post-surgery. Over half of patients with persistent pain (63 %, 34/54) reported poorly controlled postoperative pain. A somatic source was diagnosed in 54 % (29/54) with post cholecystectomy pain syndrome. CONCLUSIONS: Poorly controlled postoperative pain was reported by a third of patients. Persistent pain was present in 29 % at twelve months post-surgery. Abdominal myofascial pain syndrome should be considered as a differential diagnosis in post cholecystectomy pain syndrome.

Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT: A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS: Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION: The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE: The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

OBJECTIVE: The aim of the study is to examine the effectiveness of extracorporeal shockwave therapy in reducing pain, improving functionality, joint range of motion, quality of life, fatigue, and health status self-perception in people with myofascial pain syndrome. METHODS: PubMed, the Cochrane Library, CINAHL, the Physiotherapy Evidence Database, and SPORTDiscus were systematically searched for only randomized clinical trials published up to June 2, 2022. The main outcome variables were pain, as reported on the visual analog scale and pressure pain threshold, and functionality. A quantitative analysis was conducted using the inverse variance method and the random effects model. RESULTS: Twenty-seven studies were included ( N = 595 participants in the extracorporeal shockwave therapy group). The effectiveness of extracorporeal shockwave therapy for relieving pain was superior for the extracorporeal shockwave therapy group compared with the control group on the visual analog scale (MD = -1.7 cm; 95% confidence interval = -2.2 to -1.1) and pressure pain threshold (mean difference = 1.1 kg/cm 2 ; 95% confidence interval = 0.4 to 1.7) and functionality (standardized mean difference = -0.8; 95% confidence interval = -1.6 to -0.04) with high heterogeneity. However, no differences were found between extracorporeal shockwave therapy and other interventions as dry needling, exercises, infiltrations, and lasers interventions. CONCLUSIONS: Extracorporeal shockwave therapy is effective in relieving pain and improving functionality in patients with myofascial pain syndrome compared with control and ultrasound therapy. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the effectiveness of radial and focal extracorporeal shockwaves on pain perception, the pressure pain threshold, and functionality in people with myofascial pain syndrome; (2) Describe the intervention protocol of extracorporeal shockwave therapy to improve pain perception in people with myofascial pain syndrome; and (3) Describe the advantages and disadvantages of extracorporeal shockwave therapy versus other intervention such as dry needling. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Dry needling, trigger point electroacupuncture and motor point electroacupuncture for the treatment of myofascial pain syndrome involving the trapezius: a randomised clinical trial.

OBJECTIVE: The objective of this study was to compare trigger point (TrP) dry needling, TrP electroacupuncture and motor point electroacupuncture of the trapezius muscle for the treatment of myofascial pain syndrome (MPS). METHODS: This randomised clinical trial included 90 patients divided into three groups. Group 1 was treated with dry needling of TrPs, group 2 with intramuscular electrical stimulation of TrPs, and group 3 with electroacupuncture of motor points and/or the spinal accessory nerve. Each group received seven treatment sessions. The outcomes were the pain score measured by visual analogue scale (VAS) and quality of life evaluated by the 12-item short form (SF-12) health questionnaire. We compared the pain outcome over serial time points using growth curve analysis methods. RESULTS: Participants in the three groups experienced significant improvements in pain scores over time. The average pain level of participants in group 3 across the repeated assessments was 0.98 units lower than in group 1 (mean difference (95% confidence interval (CI) = 1.74-0.23)), p = 0.012). There were no significant differences in pain scores between participants in groups 1 and 2, and there were no significant differences in quality of life across the three groups at the end of the treatment period. CONCLUSION: Our results provide evidence that electrical stimulation of motor points and/or of the spinal accessory nerve may be superior in terms of pain relief (but not quality of life) to dry needling and possibly electrical stimulation of trigger points for the management of MPS involving the trapezius. TRIAL REGISTRATION NUMBER: TRIAL-RBR-43R7RF (Brazilian Clinical Trials Registry).

Chronic pelvic pain; more than just the bladder.

PURPOSE OF REVIEW: Chronic pelvic pain is much of a burden to those who suffer from it. Additionally, in many patients medical doctors, such as urologists are unable to identify a cause or clear pathology that can explain the pain. Still numerous patients and doctors keep on searching for a cause, focussing particularly on the pelvic organs. Lots of diagnostics and treatment methods are used but often without success. In recent years, we have gained increased insight into the mechanisms of pain and adapted the terminology accordingly. RECENT FINDINGS: Two aspects of chronic pelvic pain have gained more attention. First, the myofascial aspects, especially the role of the pelvic floor muscles in maintaining the pain and as a therapeutic option. Second, the role of the brain and the psychological aspects intertwine with the pain and its consequences also open up for alternative management options. In terminology chronic pain is now included in the ICD-11, a historical change. Introducing chronic primary pain (no cause found) helps us to look away from the organ and deal with the patient as a whole human being. SUMMARY: The findings reported here are helpful for your daily practice. Looking from a broad perspective gives the patient the feeling of being seen and heard. Working together in a multidisciplinary team makes your work easier and gives more satisfaction. VIDEO ABSTRACT: http://links.lww.com/COU/A44.