November 2013 References  Devin J. Starlanyl   for

Akdeniz S, Kelsaka E, Guldogus F.  2013.  [Retrospective evaluation of the patients with chronic pain admitted to the algology polyclinic between 2000-2010]. Agri. 25(3):115-122. [Article in Turkish]. The aim of this study is to evaluate the patients who admitted to algology polyclinic with malign and non-malign pain, sociodemographic characteristics, type of pain and pain management retrospectively….In this study we examined the medical assessment files of patients who admitted to our outpatient clinic of Algology Department for chronic pain between January 2000- December 2010. The sociodemographic characteristics of the patients, pain properties and treatments were reviewed retrospectively. Results: Within the eleven years period, a total of 6647 patients have been admitted to our clinic. 66.9% of the patients were between the ages of 19 and 64. There was no significant difference between gender. The most common causes of pain were myofascial pain, neuropathic pain, low back pain and headache. Among malignancy related cases the most common sources were gastrointestinal system, lung and breast regions. In 83.4% of patients, pharmacological and invasive treatments were utilized. The most common invasive treatment modalities were trigger point injection, dry needle application and epidural catheter application….In conclusion, pain treatments with multidisciplinary approach applied by the increasing number of pain clinics provide favorable results and patients quality of life is also increased. We hope our retrospective study may provide helpful data for future studies on chronic pain with its comprehensive base of patient data which covers an eleven years period. [This is a good study, inclusive of both malignant and nonmalignant pain.  TrP injection and dry needling were effective in the TrP component of all chronic pain.  DJS]

Alexander RE. 2013.  Clinical effectiveness of electroacupuncture in meralgia paresthetica: a case series. Acupunct Med. [Oct 23 Epub ahead of print].  “Meralgia paresthetica is a fairly common condition resulting from entrapment of the lateral femoral cutaneous nerve. I have found that acupuncture produces a rapid improvement, sometimes affecting a cure, after only one or two treatments. I therefore invited referrals in order to collect a case series….A series of 10 patients, which included two who had refused surgery, but excluded those with significant lumbar spine problems, were treated. Visual Analogue Scale pain scores and analgesic intake were recorded weekly, starting before treatment. Four patients were receiving high doses of analgesics and the average period of symptoms was 3-4 years. Acupuncture points used were BL25, GB30, GB34, GB31, GB32, Huatuojiaji and ah shi points of the buttock and thigh, up to a depth of 7.5 cm. Electroacupuncture was normally given from the second treatment….Without exception, patients were specifically tender over GB31 before they started treatment. Most were also tender over the upper lumbar spine. An average of four to five sessions of acupuncture was given. The pain scores for all 10 patients improved by at least 50%, including that of a patient with a 20-year history. At follow-up (varying from 3 to 36 months), improvement was nearly 100%. Most patients were able to stop their analgesics.  Meralgia paresthetica appears to respond rapidly to electroacupuncture. A significant trigger point at GB31 was universally present, which may aid diagnosis, although the reason for this is unclear. Further controlled studies are justified.” [All of these acupuncture point locations can be trigger points. Meralgia paresthetica can also be successfully treated with trigger point injection or dry needling in the quadriceps TrPs at that point, but must include palpation for and treatment of associated hip and thigh TrPs and identification and control of all perpetuating factors.  If all the relevant TrPs are treated and the perpetuating factors brought under control, this usually takes one treatment. DJS]

Andresson ML, Svensson B, Bergman S. 2013. Chronic widespread pain in patients with rheumatoid arthritis and the relation between pain and disease activity measures over the first 5 years.  J Rheumatol [Nov 1 Epub ahead of print.]  Chronic widespread pain is common in RA and is more often related to pain intensity and other pain qualities rather than inflammation indicators, such as the number of swollen joints and inflammatory markers.  It is important to identify the chronic widespread pain (FM) component of the patient’s illness so that can be treated adequately and taken into account.  [It is also important to identify the pain generators, such as myofascial trigger points, that are most likely the reason that the pain intensity and the inflammation are not related.  I don’t know what it will take for people to understand this.  At least this research indicates that there is “something else” other than RA inflammation influencing “RA” pain and causing/affecting the chronic widespread pain (FM).  They must become aware of co-existing trigger points. DJS]

Barbero M, Bertoli P, Cescon C et al. 2012.   Intra-rater reliability of an experienced physiotherapist in locating myofascial trigger points in upper trapezius muscle. J Man Manip Ther. 20(4):171-177. “The purpose of this study was to investigate the intra-rater reliability of a palpation protocol used for locating an MTrP in the upper trapezius muscle….Twenty-four subjects with MTrP in the upper trapezius muscle were examined by an experienced physiotherapist. During each of eight experimental sessions, subjects were examined twice in randomized order using a palpation protocol. An anatomical landmark system was defined and the MTrP location established using X and Y values.” The study showed that: “An experienced physiotherapist can reliably identify MTrP locations in upper trapezius muscle using a palpation protocol.”  [Again, it has been shown that inter-rater reliability locating trigger points requires good training and experience. Failure of any previous study demonstrated not the reliability of trigger points, but rather a failure on the part of training and experience of those who are palpating.  Doctors and other care providers, including pain researchers, MUST be proficient in palpation to accurately identify, assess and treat TrPs. The presence (or absence) of initials after a name has no relation to the ability to palpate, and hence to diagnose and treat, trigger points. DJS]

Barbero M, Cescon C, Tettamanti A et al. 2013. Myofascial trigger points and innervation zone locations in upper trapezius muscles. BMC Musculoskelet Disord. 14:179. “Myofascial trigger points (MTrPs) are hyperirritable spots located in taut bands of muscle fibres. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology…. we conclude that IZ (innervation zone) and MTrPs are located in well-defined areas in upper trapezius muscle. Moreover, MTrPs in upper trapezius are proximally located to the IZ but not overlapped.”

Bashir A, Lipton RB, Ashina S et al. 2013.  Migraine and structural changes in the brain: A systematic review and meta-analysis. Neurology. 81(14):1260-1268. “This review and meta-analysis was conducted: “To evaluate the association between migraine without aura (MO) and migraine with aura (MA) and 3 types of structural brain abnormalities detected by MRI: white matter abnormalities (WMAs), infarct-like lesions (ILLs), and volumetric changes in gray and white matter (GM, WM) regions….These data suggest that migraine may be a risk factor for structural changes in the brain. Additional longitudinal studies are needed to determine the differential influence of migraine without and with aura, to better characterize the effects of attack frequency, and to assess longitudinal changes in brain structure and function.”

Chapman CR, Bradshaw DH. 2013. Only modest long-term opioid dose escalation occurs over time in chronic nonmalignant pain management. J Pain Palliat Care Pharmacother. [Oct 21 Epub ahead of print]. “Clinical experience and the literature increasingly support differentiating chronic pain associated with malignant disease from chronic pain associated with nonmalignant conditions when defining optimal pharmacotherapy. The use of opioids for chronic nonmalignant pain has grown steadily despite the lack of a strong evidence base that can guide practice. A fundamental question is whether patients develop tolerance and need repeated dose escalations to sustain pain control. We examined opioid prescribing data from United Kingdom Clinical Practice Research Datalink longitudinal database of general practice records and tracked dose changes but not pain reports in a sample of 4035 patients who received oral or transdermal-extended release opioids for chronic nonmalignant pain. The median number of days on opioid pharmacotherapy for all patients was 311. Thirty percent of patients never changed doses during the course of treatment. In patients who never changed medications, the mean morphine equivalent 24-hour dose increased from beginning to end of opioid pharmacotherapy only by 1.4 fold…and was independent of both age and gender. Comparison across extended release morphine, oxycodone, and fentanyl revealed that it was significantly greatest for patients using fentanyl and least for those using morphine.”

Ge HY, Monterde S, Graven-Nielsen T et al. 2013. Latent myofascial trigger points are associated with an increased intramuscular electromyographic activity during synergistic muscle activation. J Pain. [Nov 1 Epub ahead of print]. “The aim of this study was to evaluate intramuscular muscle activity from a latent myofascial trigger point (MTP) in a synergistic muscle during isometric muscle contraction. Intramuscular activity was recorded with an intramuscular electromyographic (EMG) needle inserted into a latent MTP or a non-MTP in upper trapezius at rest and during isometric shoulder abduction at 90° performed at 25% of maximum voluntary contraction in 15 healthy subjects. Surface EMGs were recorded from the middle deltoid muscle, upper-, middle-, and lower- parts of the trapezius muscle. Maximal pain intensity and referred pain induced by EMG needle insertion and maximal pain intensity during contraction were recorded on a visual analogue scale (VAS). The results showed that higher VAS scores were observed following needle insertion and during muscle contraction for latent MTPs than non-MTPs…. The intramuscular EMG activity in the upper trapezius muscle was significantly higher at rest and during shoulder abduction at latent MTPs compared with non-MTPs…. This study provides evidence that latent MTPs are associated with increased intramuscular, but not surface, EMG amplitude of synergist activation. The increased amplitude of synergistic muscle activation may result in incoherent muscle activation pattern of synergists inducing spatial development of new MTPs and the progress to active MTPs.”  [This study shows one way in which TrPs can develop satellite TrPs, and myofascial trigger point pain and dysfunction can spread to muscles recruited by TrP-weakened muscles to help them.  The newly recruited muscles, now also overworked doing tasks they were not designed to do, then need other muscles to help them perform their tasks.  This can lead to the false impression of the presence of a progressive illness.  DJS]

Giacomelli C, Talarico R, Bombardieri S et al. 2013. The interaction between autoimmune diseases and fibromyalgia: risk, disease course and management. Expert Rev Clin Immunol. 9(11):1069-1076. “Fibromyalgia (FM) is a common non-autoimmune rheumatologic disease with a wide range of symptoms that worsen the clinical status of patients. Several authors have tried to identify a putative autoimmune biomarker but, unfortunately, without positive results. Moreover, the altered pain perception characteristic of FM patients is similar in other autoimmune rheumatologic and non-rheumatologic diseases, in fact the pain in FM is not strictly tied to an organic disease; the perception and the severity of it are comparable with those of autoimmune conditions, for example, the polymyalgia rheumatica. In this review, we focus on the FM comorbidities, especially related to autoimmune rheumatologic and non-rheumatologic conditions”. [This review from Italy clarifies, once again, that fibromyalgia is not itself an auto-immune disease, but can co-exist with auto-immune diseases.  The pain of FM is as severe as many autoimmune illnesses.  They do not grasp the trigger point generation of the “FM” pain and dysfunction, and that trigger points can generate pain and dysfunction in any illness.  DJS]

Grieve R, Cranston A, Henderson A et al. 2013.  The immediate effect of triceps surae myofascial trigger point therapy on restricted active ankle joint dorsiflexion in recreational runners: A crossover randomized controlled trial. J Bodyw Mov Ther. 17(4):453-461. “To investigate the immediate effect on restricted active ankle joint dorsiflexion range of motion (ROM), after a single intervention of myofascial trigger point (MTrP) therapy on latent triceps surae MTrPs in recreational runners”….a crossover randomized controlled trial was conducted on: “Twenty-two recreational runners (11 men and 11 women…with a restricted active ankle joint dorsiflexion and presence of latent MTrPs….Participants were screened for a restriction in active ankle dorsiflexion in either knee flexion (soleus) or knee extension (gastrocnemius) and the presence of latent MTrPs. Participants were randomly allocated a week apart to both the intervention (combined pressure release and 10 s passive stretch) and the control condition….A clinically meaningful and statistically significant increase in ankle ROM in the intervention compared to the control group was achieved, for the soleus…and the gastrocnemius….”

Hassett AL, Hilliard PE, Goesling J et al. 2013.  Reports of chronic pain in childhood and adolescence among patients at a tertiary care pain clinic. J Pain. 14(11):1390-1397. “Although chronic pain in childhood can last into adulthood, few studies have evaluated the characteristics of adults with chronic pain who report childhood chronic pain. Thus, 1,045 new patients…at an academic tertiary care pain clinic were prospectively evaluated using validated self-report questionnaires. Patients also responded to questions about childhood pain. We found that almost 17%…of adult chronic pain patients reported a history of chronic pain in childhood or adolescence, with close to 80% indicating that the pain in childhood continues today. Adults reporting childhood chronic pain were predominantly female (68%), commonly reported widespread pain (85%), and had almost 3 times the odds of meeting survey criteria for fibromyalgia….than those denying childhood chronic pain. Similarly, those with childhood pain had twice the odds of having biological relatives with chronic pain….and almost 3 times the odds of having relatives with psychiatric illness….. Lastly, compared to patients who did not report childhood chronic pain, those who did were more likely to use neuropathic descriptors for their pain…, have slightly worse functional status…, and have increased anxiety….Our study revealed that 1 in 6 adult pain patients reported pain that dated back to childhood or adolescence. In such patients, evidence suggested that their pain was more likely to be widespread, neuropathic in nature, and accompanied by psychological comorbidities and decreased functional status.”  [This is logical. The longer one has had pain, especially pain that often is accompanied by lack of understanding on the part of medical and nonmedical care providers and is insufficiently addressed, and the more genetic factors involved the more chance of developing pain that would lead one to a tertiary pain facility eventually. This paper offers some fascinating insights in chronic pain, and in the treatment of pain and dysfunction, of lack thereof, in early years.  We must change this pattern and prevent chronicity by identifying and treating trigger points and other pain generators as soon as possible.  DJS] 

Lan C, Chen SY, Lai JS et al. 2013.  Tai chi chuan in medicine and health promotion. Evid Based Complement Alternat Med. 2013:502131. “Tai chi chuan (Tai Chi) is a Chinese traditional mind-body exercise, and recently, it becomes popular worldwide. During the practice of Tai Chi, deep diaphragmatic breathing is integrated into body motions to achieve a harmonious balance between body and mind and to facilitate the flow of internal energy (Qi). Participants can choose to perform a complete set of Tai Chi or selected movements according to their needs. Previous research substantiates that Tai Chi has significant benefits to health promotion, and regularly practicing Tai Chi improves aerobic capacity, muscular strength, balance, health-related quality of life, and psychological well-being. Recent studies also prove that Tai Chi is safe and effective for patients with neurological diseases (e.g., stroke, Parkinson's disease, traumatic brain injury, multiple sclerosis, cognitive dysfunction), rheumatological disease (e.g., rheumatoid arthritis, ankylosing spondylitis, and fibromyalgia), orthopedic diseases (e.g., osteoarthritis, osteoporosis, low-back pain, and musculoskeletal disorder), cardiovascular diseases (e.g., acute myocardial infarction, coronary artery bypass grafting surgery, and heart failure), chronic obstructive pulmonary diseases, and breast cancers. Tai Chi is an aerobic exercise with mild-to-moderate intensity and is appropriate for implementation in the community. This paper reviews the existing literature on Tai Chi and introduces its health-promotion effect and the potential clinical applications.”

Manson J, Rotondi M, Jamnik V et al. 2013. Effect of tai chi on musculoskeletal health-related fitness and self-reported physical health changes in low income, multiple ethnicity mid to older adults. BMC Geriatr. 13(1):114. “Two hundred and nine ethnically diverse mid to older community dwelling Canadian adults residing in low income neighborhoods were enrolled in a 16 week Yang style TC program. Body Mass Index and select musculoskeletal fitness measures including upper and lower body strength, low back flexibility and self-reported physical health measured by SF 36 were collected pre and post the TC program. Determinants of health such as age, sex, marital status, education, income, ethnicity of origin, multi-morbidity conditions, weekly physical activity, previous TC experience as well as program adherence were examined as possible musculoskeletal health-related fitness change predictors….These results reveal that TC has the potential of having a beneficial influence on musculoskeletal health-related fitness and self-reported physical health in a mid to older low socioeconomic, ethnically diverse sample.”


Pinto Fiamengui LM, Freitas de Carvalho JJ, Cunha CO et al. 2013. The influence of myofascial temporomandibular disorder pain on the pressure pain threshold of women during a migraine attack.  J Orofac Pain. 27(4):343-349. Thirty-four women between the ages of 18-60 were separated into a group with migraine and one with migraine and myofascial pain, that later category being assumed as the same as temporomandibular pain. The pressure pain threshold (PPT) on the masseter, anterior temporalis, and Achilles tendon were taken by algometer when the patients were pain free, and during a migraine. “Results: Significantly lower PPT values were found during the migraine attack, especially for women with concomitant myofascial pain, regardless of the side of the reported pain.  Conclusion: Migraine attack is associated with a significant reduction in PPT values of masticatory muscles, which appears to be influenced by the presence of myofascial TMD pain.”  [Dentists, and psychologists, must become aware of pain and dysfunction-generating TrPs that can occur over the whole body, so that they cease the confusing use of “myofascial pain” as synonymous with TMJD.  DJS]


Plazier M, Dekelver I, Vanneste S et al. 2013. Occipital nerve stimulation in fibromyalgia: A double-blind placebo-controlled pilot study with a six-month follow-up. Neuromodulation. [Oct 7 Epub ahead of print]. “The goal of this study is to evaluate the effectiveness of occipital nerve stimulation (ONS) as a surgical treatment for fibromyalgia in a placebo-controlled design….Eleven patients were selected based on the American College of Rheumatology-90 criteria and implanted with an occipital nerve trial-lead stimulator. Baseline scores for pain, mood, and fatigue were acquired, and patients were randomized in a ten-week double-blinded crossover design with placebo and effective subsensory threshold stimulation (no paresthesias). After finalizing the trial, nine patients were implanted permanently; evaluation was performed prior to surgery and at six months after surgery for pain, fatigue, and mood of the number of trigger points and overall morbidity. Significant results were found during the trial for a decrease in pain intensity (39.74%) on visual analogue scale …and pain catastrophizing scale (PCS) during effective stimulation. A total of 9/11 patients responded to trial treatment; however, in two patients, this might be a placebo effect, recognizable due to the study design. Six months after permanent implantation, pain intensity remained decreased (44.01%) on VAS…. Besides the VAS, significant changes were noted for PCS, fatigue (modified fatigue impact scale), the number of trigger points, and overall morbidity (fibromyalgia impact questionnaire). There were no serious adverse events. Our data strongly suggest that ONS is beneficial in the treatment of fibromyalgia. The beneficial effects are stable at six months after permanent implantation. Subsensory threshold stimulation is feasible in designing a placebo-controlled trial.” [Although the authors recognize the importance of the “trigger point count”, they fail to recognize the trigger points as the actual generators of pain and dysfunction.  Perhaps if the trigger points had been treated and perpetuating factors identified and controlled, the surgery would not have been necessary. Then again, the surgery might have taken care of some of the perpetuating factors. We will not know, because the authors did not understand the role of the trigger points. DJS]


Shmushkevich Y, Kalichman L. 2013. Myofascial pain in lateral epicondylalgia: A review. J Bodyw Mov Ther. 17(4):434-439. “There is an ongoing debate about the myofascial component, characterized by the presence of myofascial trigger points (MTrPs) in lateral epicondylalgia (LE)….” The objectives of this study were: “To review current evidence of the association between myofascial pain and LE, including efficacy of treatment, focusing on myofascial pain….PubMed, Google Scholar and PEDro databases were searched without search limitations from inception until October 2012 for terms relating to LE and MTrPs….Two observational studies showed a high prevalence of MTrPs in LE patients compared to healthy controls. Three randomized controlled trials demonstrated significant improvement in pain and functional outcomes after application of soft tissue techniques, focusing on the myofascial component. Myofascial pain and MTrPs may be part of the LE etiology. Treatment focusing on the myofascial component seems to be effective in reducing pain and improving function in patients with LE. Additional trials are essential to attain a solid conclusion.” [Since some studies still use the term “myofascial pain” to mean TMJD, and so very many researchers are not even aware of myofascial trigger points or lack the training and experience needed to palpate them, previous research is only as good as the training.  There should be no “ongoing debate” about the myofascial component of LE.  There are only those experienced and well-trained in the techniques of palpating TrPs and those who are not. Disagreements between those who are trained and those who are not, does not constitute a true debate.  To have a controversy, there must be science on both sides.  Researchers who do not understand the ubiquity of TrPs are churning out incomplete and often flawed research.  Quantity does not equal quality.  The “debate” will continue until they all become enlightened.  Until then, bad research will beget more bad research.  This study is not bad, but reflects the need for education. DJS]  

Staud R, Weyl EE, Bartley E et al. 2013. Analgesic and anti-hyperalgesic effects of muscle injections with lidocaine or saline in patients with fibromyalgia syndrome. Eur J Pain. [Nov 5 Epub ahead of print.] This double-blind controlled study of 62 women with fibromyalgia utilized injection into trapezius and gluteal trigger points with either saline or lidocaine.  The results indicate that injection of peripheral trigger point pain generators can reliably and significantly reduce clinical fibromyalgia pain.  This research strongly suggests that, at least in women, it is the input from peripheral pain generators such as trigger points that maintain the mechanical and heat hyperalgesia of fibromyalgia. “…effects of muscle injections on hyperalgesia were greater for lidocaine than saline; the effects on clinical pain were similar for both injectates.”

Umeda M, Corbin LW, Maluf KS. 2013. Pain mediates the association between physical activity and the impact of fibromyalgia on daily function. Clin Rheumatol. [Sep 13 Epub ahead of print].  “This study quantified the association between recreational physical activity and daily function in women with fibromyalgia, and determined if this association is mediated by symptoms of pain, depression, or body mass….These results indicate that the intensity of musculoskeletal pain, rather than depressive symptoms or body mass, mediates the association between physical activity and daily function among women with fibromyalgia.” This study shows that pain itself is the driving factor determining the amount of activity and function in FM women, and it is not the “sedentary nature” or depression that drives the pain.

Ustun N, Arslan F, Mansuroglu A et al. 2013. Efficacy of EMLA cream phonophoresis comparison with ultrasound therapy on myofascial pain syndrome of the trapezius: a single-blind, randomized clinical study. Rheumatol Int. [Oct 23 Epub ahead of print]. This study from Turkey took 50 myofascial pain syndrome patients (42 female and 8 male), and separated them into groups where they received either phonophoresis (PH) with EMLA local anesthetic (2.5% lidocaine, 2.5% prilocaine) cream, or ultrasound (US).  The groups received treatment 10 minutes a day for 15 sessions on all active trapezius trigger points.  The study found: “EMLA cream phonophoresis is more effective than conventional ultrasound therapy in terms of pain and associated neck disability…”