July 2014 References  Devin J. Starlanyl   for http://www.sover.net/~devstar

Bank PJ, Peper CL, Marinus J et al. 2013. Motor dysfunction of complex regional pain syndrome is related to impaired central processing of proprioceptive information. J Pain. 14(11):1460-1474. “Our understanding of proprioceptive deficits in complex regional pain syndrome (CRPS) and its potential contribution to impaired motor function is still limited. To gain more insight into these issues, we evaluated accuracy and precision of joint position sense over a range of flexion-extension angles of the wrist of the affected and unaffected sides in 25 chronic CRPS patients and in 50 healthy controls. The results revealed proprioceptive impairment at both the patients' affected and unaffected sides, characterized predominantly by overestimation of wrist extension angles. Precision of the position estimates was more prominently reduced at the affected side. Importantly, group differences in proprioceptive performance were observed not only for tests at identical percentages of each individual's range of wrist motion but also when controls were tested at wrist angles that corresponded to those of the patient's affected side. More severe motor impairment of the affected side was associated with poorer proprioceptive performance. Based on additional sensory tests, variations in proprioceptive performance over the range of wrist angles, and comparisons between active and passive displacements, the disturbances of proprioceptive performance most likely resulted from altered processing of afferent (and not efferent) information and its subsequent interpretation in the context of a distorted "body schema….The present results point at a significant role for impaired central processing of proprioceptive information in the motor dysfunction of CRPS and suggest that therapeutic strategies aimed at identification of proprioceptive impairments and their restoration may promote the recovery of motor function in CRPS patients.”

Biasi G, Di Sabatino V, Ghizzani A et al. 2014. Chronic pelvic pain: comorbidity between chronic musculoskeletal pain and vulvodynia. Reumatismo. 66(1):87-91. “Chronic pelvic pain (CPP) is a common condition that has a major impact on the quality of life of both men and women. Male CPP is usually attributable to well-defined urogenital conditions (most frequently infectious/non infectious prostatic diseases) or musculoskeletal or bowel diseases, whereas the features of female CPP are much more complex and are of particular clinical and epidemiological importance. It is a multifactorial syndrome that can be due to diseases of the urogenital, gastrointestinal, or musculoskeletal systems, or to neurological or neuropsychiatric disorders. It is not always easy to identify its predominant pathogenesis, although it often occurs as a central sensitization syndrome triggered by an initial stimulus which is no longer detectable and only manifests itself clinically through pain. In this respect, there are some very interesting relationships between vulvodynia and fibromyalgic syndrome, as identified in a preliminary study of women with chronic musculoskeletal pain in which it was demonstrated that vulvar pain plays an important role, although it is often overlooked and undiagnosed.” [Myofascial trigger points are often responsible for or contribute to chronic pelvic pain and/or vulvodynia.  There are excellent research articles on this. See Doggweiler R. DJS]

Bromberg MH, Schechter NL, Nurko S et al. 2014. Persistent pain in chronically ill children without detectable disease activity. Pain Manag. 4(3):211-219. “Children with organic diseases may experience persistent pain in the presence of controlled disease, as evidenced by little or no measurable disease activity or inflammation. Historically, dualistic definitions of pain have informed standard diagnostic approaches to persistent pain; aggressive investigation and treatment targeting underlying disease, even in the absence of evidence indicating disease escalation. Evidence across disease populations, in children with inflammatory bowel disease, sickle cell disease, and juvenile idiopathic arthritis indicates that persistent pain in these conditions may be better conceptualized as functional in nature, potentially resulting from disordered somatosensory processing including central sensitization. Applying a biopsychosocial understanding of persistent pain and multidisciplinary functional pain management strategies may lead to improved health outcomes.”

Cassisi G, Sarzi-Puttini P, Casale R et al. 2014. Pain in fibromyalgia and related conditions. Reumatismo. 66(1):72-86. “Pain is the hallmark symptom of fibromyalgia (FM) and other related syndromes, but quite different from that of other rheumatic diseases, which depends on the degree of damage or inflammation in peripheral tissues. Sufferers are often defined as patients with chronic pain without an underlying mechanistic cause, and these syndromes and their symptoms are most appropriately described as ‘central pain’, ‘neuropathic pain’, ‘nonnociceptive pain’ or ‘central sensitivity syndromes’. The pain is particular, regional or widespread, and mainly relates to the musculoskeletal system; hyperalgesia or allodynia are typical. Its origin is currently considered to be distorted pain or sensory processing, rather than a local or regional abnormality. FM is probably the most important and extensively described central pain syndrome, but the characteristics and features of FM-related pain are similar in other disorders of particular interest for rheumatologists, such as myofascial pain syndromes and temporo-mandibular joint disorders, and there is also an intriguing overlap between FM and benign joint hypermobility syndrome. This suggests that the distinctive aspects of pain in these idiopathic or functional conditions are caused by central nervous system hypersensitivity and abnormalities.”

Chen WN, Lee CH, Lin SH et al.  2014. Roles of ASIC3, TRPV1, and NaV1.8 in the transition from acute to chronic pain in a mouse model of fibromyalgia. Mol Pain. 10(1):40. “Tissue acidosis is effective in causing chronic muscle pain. However, how muscle nociceptors contribute to the transition from acute to chronic pain is largely unknown….Here we showed that a single intramuscular acid injection induced a priming effect on muscle nociceptors of mice. The primed muscle nociceptors were plastic and permitted the development of long-lasting chronic hyperalgesia induced by a second acid insult. The plastic changes of muscle nociceptors were modality-specific and required the activation of acid-sensing ion channel 3 (ASIC3) or transient receptor potential cation channel V1 (TRPV1). Activation of ASIC3 was associated with increased activity of tetrodotoxin (TTX)-sensitive voltage-gated sodium channels but not protein kinase Cepsilon (PKCepsilon) in isolectin B4 (IB4)-negative muscle nociceptors. In contrast, increased activity of TTX-resistant voltage-gated sodium channels with ASIC3 or TRPV1 activation in NaV1.8-positive muscle nociceptors was required for the development of chronic hyperalgesia. Accordingly, compared to wild type mice, NaV1.8-null mice showed briefer acid-induced hyperalgesia (5 days vs. >27 days)…..ASIC3 activation may manifest a new type of nociceptor priming in IB4-negative muscle nociceptors. The activation of ASIC3 and TRPV1 as well as enhanced NaV1.8 activity is essential for the development of long-lasting hyperalgesia in acid-induced, chronic, widespread muscle pain.”  Free Article

Fernandez-de-Las-Penas C, Courtney CA. 2014.  Clinical reasoning for manual therapy management of tension type and cervicogenic headache.  J Man Manip Ther. 22(1):44-50.

“In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches.”

Frange C, Hirotsu C, Hachul H et al. 2014. Fibromyalgia and sleep in animal models: a current overview and future directions. Curr Pain Headache Rep.18(8):434. “Sleep disorders are highly prevalent in patients with fibromyalgia (FM). Many of the daytime symptoms, such as chronic pain and fatigue, may be related to the non-restorative sleep patterns associated with the disease. Pain influences the sleep process and sleep disturbances decrease the pain threshold in a reciprocal framework. Thus, understanding the link between sleep and FM has become an important research topic in basic science. Therefore, in the current review we connect these topics and provide some insights into the cyclic relationship between sleep and pain, which has been addressed mainly in animal models. Additionally, we highlight the urgent need for sleep studies in FM animal models, which might improve the knowledge base and accelerate advances in this field.”

Gerdle B, Ghafouri B, Ernberg M et al. 2014. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res.7:313-326. “These results indicate that peripheral muscle alterations are parts of the activated pain mechanisms in common chronic pain conditions. Muscle alterations have been reported in fibromyalgia syndrome and chronic widespread pain, but more studies are needed before definite conclusions can be drawn. For other substances, results are inconclusive across studies and patient groups.”

Gonzalez B, Baptista TM, Branco JC et al. 2014.  Fibromyalgia characterization in a psychosocial approach.  Psychol Health Med. 25:1-6. “This study aimed to characterize a group of women diagnosed with fibromyalgia, evaluating the relationship between personality and psychopathology, health status (disability, physical health, mental health, and pain), and potentially traumatic life events (PTLE) before the onset of the syndrome. The disability caused by fibromyalgia, physical and mental health status, pain, PTLE in childhood and in the course of life, and personality were assessed in a sample of 50 women with fibromyalgia, age 25-70 years ….. A multiple correspondence analysis with all the variables identified two types of profiles and a K-Means cluster analysis confirmed two groups of patients: cluster 1 (n = 36), with better health and less psychopathological problems, named ‘Better adjustment’ and cluster 2 (n = 14), with less health and more personality problems, named ‘Disorder and disability.’ Pertaining to personality only, a K-Means cluster analysis replicated the three classic personality profiles (normal, neurotic, and psychopathological) identified in chronic pain patients; and the normal profile was the more prevalent (n = 22). The results enhance the importance of recognizing the heterogeneity of fibromyalgia population and the great closeness between personality and physical health, with the PTLE having a less important role than expected.”  

Imamura M, Targino RA, Hsing WT et al.  2014. Concentration of cytokines in patients with osteoarthritis of the knee and fibromyalgia. Clin Interv Aging. 9:939-944. “Patients with knee osteoarthritis and fibromyalgia with the same duration and intensity of pain demonstrate similar concentrations of cytokines. Aging may play a role in cytokine profile, a finding not so extensively addressed in the literature and one that should be further investigated.”

Jurgens TP, Sawatzki A, Henrich F et al. 2014. An improved model of heat-induced hyperalgesia--repetitive phasic heat pain causing primary hyperalgesia to heat and secondary hyperalgesia to pinprick and light touch. PLoS One. 9(6):e99507. “This study tested a modified experimental model of heat-induced hyperalgesia, which improves the efficacy to induce primary and secondary hyperalgesia and the efficacy-to-safety ratio reducing the risk of tissue damage seen in other heat pain models. Quantitative sensory testing was done in eighteen healthy volunteers before and after repetitive heat pain stimuli (60 stimuli of 48°C for 6 s) to assess the impact of repetitive heat on somatosensory function in conditioned skin (primary hyperalgesia area) and in adjacent skin (secondary hyperalgesia area) as compared to an unconditioned mirror image control site. Additionally, areas of flare and secondary hyperalgesia were mapped, and time course of hyperalgesia determined. After repetitive heat pain conditioning we found significant primary hyperalgesia to heat, and primary and secondary hyperalgesia to pinprick and to light touch (dynamic mechanical allodynia). Acetaminophen (800 mg) reduced pain to heat or pinpricks only marginally by 11% and 8%, respectively (n.s.), and had no effect on heat hyperalgesia. In contrast, the areas of flare (-31%) and in particular of secondary hyperalgesia (-59%) as well as the magnitude of hyperalgesia (-59%) were significantly reduced…. Thus, repetitive heat pain induces significant peripheral sensitization (primary hyperalgesia to heat) and central sensitization (punctate hyperalgesia and dynamic mechanical allodynia). These findings are relevant to further studies using this model of experimental heat pain as it combines pronounced peripheral and central sensitization, which makes a convenient model for combined pharmacological testing of analgesia and anti-hyperalgesia mechanisms related to thermal and mechanical input.”


Kietrys DM, Palombaro KM, Mannheimer JS. 2014. Dry needling for management of pain in the upper quarter and craniofacial region. Curr Pain Headache Rep.18(8):437. “Dry needling is a therapeutic intervention that has been growing in popularity. It is primarily used with patients that have pain of myofascial origin. This review provides background about dry needling, myofascial pain, and craniofacial pain. We summarize the evidence regarding the effectiveness of dry needling. For patients with upper quarter myofascial pain, a 2013 systematic review and meta-analysis of 12 randomized controlled studies reported that dry needling is effective in reducing pain (especially immediately after treatment) in patients with upper quarter pain. There have been fewer studies of patients with craniofacial pain and myofascial pain in other regions, but most of these studies report findings to suggest the dry needling may be helpful in reducing pain and improving other pain related variables such as the pain pressure threshold. More rigorous randomized controlled trials are clearly needed to more fully elucidate the effectiveness of dry needling.”

Lee YH, Kim JH, Song GG. 2014. Association between the COMT Val158Met polymorphism and fibromyalgia susceptibility and fibromyalgia impact questionnaire score: a meta-analysis.  Rheumatol Int. [Jun 21 Epub ahead of print.] “The aim of this study was to explore whether the catechol-O-methyltransferase (COMT) Val158Met polymorphism is associated with susceptibility to fibromyalgia and fibromyalgia impact questionnaire (FIQ) score in fibromyalgia patients. We conducted a meta-analysis of the associations of the COMT Val158Met polymorphism with fibromyalgia risk as well as FIQ score in fibromyalgia patients. A total of 993 fibromyalgia patients and 778 controls from 10 studies on the COMT Val158Met polymorphism and 538 fibromyalgia patients from 5 studies on the COMT Val158Met polymorphism and FIQ score were included in this meta-analysis. The meta-analysis revealed an association between fibromyalgia and the COMT Met/Met + Val/Met genotype in all study subjects (odds ratio (OR) 1.635, 95 % confidence interval (CI) 1.029-2.597, p = 0.037). However, stratification by ethnicity indicated no association between the Met/Met + Val/Met genotype and fibromyalgia in the European and Turkish populations (OR 1.202, 95 % CI 0.876-1.649, p = 0.255; OR 2.132, 95 % CI 0.764-5.949, p = 0.148, respectively). Analysis using other genetic models showed no association between the COMT Val158Met polymorphism and fibromyalgia. The meta-analysis also revealed that the FIQ score was significantly higher in individuals with the COMT Met/Met genotype than in those with the Val/Val genotype…and the Val/Met genotype... This meta-analysis identified an association between fibromyalgia risk and the COMT Val158Met polymorphism as well as the FIQ score in fibromyalgia patients.”   

Nascimento SS, Camargo EA, DeSantana JM et al. 2014. Linalool and linalool complexed in β-cyclodextrin produce anti-hyperalgesic activity and increase Fos protein expression in animal model for fibromyalgia. Naunyn Schmiedebergs Arch Pharmacol. [Jun 24 Epub ahead of print.]

“The analgesic activity of (-)-linalool (LIN), a monoterpene present in essential oils of Lamiaceae species, has been previously demonstrated in rodents. However, its possible use in the treatment of fibromyalgia (FM) was never demonstrated. Additionally, as a short half-life is a limitation for the LIN medicinal application, the employment of drug delivery systems has been used to improve pharmaceutical properties of this compound. We investigated the anti-nociceptive effect of LIN, isolated or in β-cyclodextrin complex (LIN-CD), in an animal model of chronic non-inflammatory muscle pain (a FM animal model), as well as its effect on the central nervous system (CNS)….our results suggest that LIN-CD improved analgesic profile of LIN, with a probable involvement of descending pain pathways and the anti-nociceptive effect of linalool in an animal model of chronic non-inflammatory muscle pain. So far, only the investigations in animal models of inflammatory pain and supraspinatus were published.” [Linolool is an aromatic compound found in many herbs, including coriander, basil, cinnamon, lavender, and mints. DJS]

Neumann DJ. 2014. July 2014 book reviews. Orthop Sports Phys Ther. 44(7):542-546. JOSPT offers invited reviews of current titles. The July 2014 column includes 6 reviews of the following books: Physical Therapy Management of Patients With Spinal Pain: An Evidence-Based Approach; Traumatology for the Physical Therapist; Evidence-Based Rehabilitation: A Guide to Practice, Third Edition; Healing Through Trigger Point Therapy: A Guide to Fibromyalgia, Myofascial Pain, and Dysfunction; Your Headache Isn't All in Your Head: Neuroscience Education for Patients With Headache Pain; and Disorders of the Shoulder: Diagnosis and Management Package, Third Edition.

Nijs J, Malfliet A, Ickmans K et al. 2014.  Treatment of central sensitization in patients with 'unexplained' chronic pain: an update. Expert Opin Pharmacother. 15:1-13. “Central sensitization (CS) is present in a variety of chronic pain disorders, including whiplash, temporomandibular disorders, low back pain, osteoarthritis, fibromyalgia, headache, lateral epicondylalgia among others. In spite of our increased understanding of the mechanisms involved in CS pain, its treatment remains a challenging issue. Areas covered: An overview of the treatment options we have for desensitizing the CNS in patients with CS pain is provided. These include strategies for eliminating peripheral sources of nociception, as well as pharmacotherapy and conservative interventions that primarily address top-down (i.e., brain-orchestrated) mechanisms. Expert opinion: A combination of different strategies, each targeting a different 'desensitizing' mechanism, might prove superior over monotherapies. Such combined therapy may include both bottom-up and top-down (e.g., opioids, combined μ-opioid receptor agonist and noradrenaline reuptake inhibitor drugs) strategies. Topically applied analgesic therapies have strong potential for (temporally) decreasing peripheral nociceptive input (bottom-up approach). Targeting metabolic (e.g., ketogenic diets) and neurotrophic factors (e.g., decreasing brain-derived neurotrophic factor) are promising new avenues for diminishing hyperexcitability of the CNS in central sensitization pain patients. Addressing conservative treatments, pain neuroscience education, cognitive behavioral therapy and exercise therapy are promising treatments for CS pain.”

Sawynok J. 2014. Topical and peripheral ketamine as an analgesic.  Anesth Analg. 119(1):170-178. “Ketamine, in subanesthetic doses, produces systemic analgesia in chronic pain settings, an action largely attributed to block of N-methyl-D-aspartate receptors in the spinal cord and inhibition of central sensitization processes. N-methyl-D-aspartate receptors also are located peripherally on sensory afferent nerve endings, and this provided the initial impetus for exploring peripheral applications of ketamine. Ketamine also produces several other pharmacological actions (block of ion channels and receptors, modulation of transporters, anti-inflammatory effects), and while these may require higher concentrations, after topical (e.g., as gels, creams) and peripheral application (e.g., localized injections), local tissue concentrations are higher than those after systemic administration and can engage lower affinity mechanisms. Peripheral administration of ketamine by localized injection produced some alterations in sensory thresholds in experimental trials in volunteers and in complex regional pain syndrome subjects in experimental settings, but many variables were unaltered. There are several case reports of analgesia after topical application of ketamine given alone in neuropathic pain, but controlled trials have not confirmed such effects. A combination of topical ketamine with several other agents produced pain relief in case, and case series, reports with response rates of 40% to 75% in retrospective analyses. In controlled trials of neuropathic pain with topical ketamine combinations, there were improvements in some outcomes, but optimal dosing and drug combinations were not clear. Given orally (as a gargle, throat swab, localized peritonsillar injections), ketamine produced significant oral/throat analgesia in controlled trials in postoperative settings. Topical analgesics are likely more effective in particular conditions (patient factors, disease factors), and future trials of topical ketamine should include a consideration of factors that could predispose to favorable outcomes.”

Shaffer SM, Brismee JM, Sizer PS et al. 2014. Temporomandibular disorders. Part 2: conservative management. J Man Manip Ther. 22(1):13-23.  “Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described in part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables.”


Skorupska E, Rychlik M, Pawelec W et al. 2014. Trigger point-related sympathetic nerve activity in chronic sciatic leg pain: a case study. Acupunct Med. [Jun 26 Epub ahead of print.] “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 cm2 and then gradually decreased.… 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.”          


Smith SC, Wagner MS. 2014. Clinical endocannabinoid deficiency (CECD) revisited: Can this concept explain the therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? Neuro Endocrinol Lett. 35(3):198-201.

“Subsequent research has confirmed that underlying endocannabinoid deficiencies indeed play a role in migraine, fibromyalgia, irritable bowel syndrome and a growing list of other medical conditions. Clinical experience is bearing this out. Further research and especially, clinical trials will further demonstrate the usefulness of medical cannabis. As legal barriers fall and scientific bias fades this will become more apparent.”

Switlick T, Kernozek TW, Meardon S. 2014. Differences in Joint Position Sense and Vibratory Threshold in Runners With and Without a History of Over-Use Injury. J Sport Rehabil. [Jun 23 Epub ahead of print.] “A relationship between altered postural control and injury has been reported in sports. Sensorimotor function serves a fundamental role in postural control and is not often studied in runners. Persons who sustain running injury may have altered sensorimotor function contributing to risk of injury or re-injury….Differences in ankle eversion proprioception between runners with a history of ankle and foot injuries and non-injured runners were observed. Runners with a history of injury also displayed an increased vibratory threshold in the arch region compared to non-injured runners. Poor ankle joint position sense and increased plantar sensitivity suggest altered sensorimotor function following injury. These factors may influence underlying postural control and contribute to altered loading responses commonly observed in injured runners.”  [These symptoms strongly suggest associated trigger points, both active and latent, and patients should be assessed for TrPs before they continue running.  DJS]

Thiagarajah AS, Eades LE, Thomas PR et al. 2014. GILZ: Glitzing up our understanding of the glucocorticoid receptor in psychopathology. Brain Res. [Jun 12 Epub ahead of print.]

“Dysfunction of the hypothalamic-pituitary-adrenal axis, particularly the glucocorticoid receptor, is a commonly implicated link between stress and psychopathology. GR abnormalities are frequently reported in depression, and these anomalies must be resolved before depressive symptoms remit. This biological finding is rendered clinically relevant by the knowledge that only select antidepressants alter GR function. The relationship between GR dysfunction and other diseases associated with psychiatric stress, such as post-traumatic stress disorder (PTSD) and fibromyalgia, is also documented. However, as laboratory constraints limit the utility of GR testing, other measures of GR activity, such as levels of GR-induced genes, may have greater clinical value. In this review, glucocorticoid-induced leucine zipper (GILZ), a product of GR-initiated gene transcription, will be discussed in the context of GR dysfunction in psychopathology.”

van der Esch M, Holla JF, van der Leeden M et al. 2014. Decrease of muscle strength is associated with increase of activity limitations in early knee osteoarthritis: 3-year results from the Cohort Hip and Cohort Knee study. Arch Phys Med Rehabil. [Jun 27 Epub ahead of print.]

“In patients with early knee OA, decreased muscle strength is associated with an increase in activity limitations. Our results are a step towards understanding the role of muscle weakness in the development of activity limitations in knee OA. Further, well-designed experimental studies are indicated to establish the causal role of muscle weakness in activity limitations.” [Myofascial trigger points co-exist with OA, and often cause the muscle weakness and proprioceptive dysfunctions described. It would be of value to have these patients assessed for TRPs, as the symptoms might be relieved with treatment of TrPs. DJS]

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