Search

Objective: To determine the presence of widespread pressure hyperalgesia in multiple sclerosis (MS) patients with and without pain and its association with pain and fatigue., Methods: A total of 108 individuals with definite MS, 49 men and 59 women (mean age, 44±8 y) and 108 age-matched and sex-matched pain-free controls (mean age, 44±9 y) were included. Fifty patients (n=58, 54%) reported pain and 50 (46%) did not. Pressure pain threshold (PPT) was bilaterally assessed over supraorbital, infraorbital, mental, median, radial and ulnar nerve trunks, C5-C6 joint, second metacarpal, and tibialis anterior muscle by an assessor blinded to the patient's condition. The intensity of pain was assessed with a numerical pain rate scale (0 to 10), fatigue was determined with the Fatigue Impact Scale, and depression was evaluated with the Beck Depression Inventory., Results: The analyses of covariance revealed that PPT were significantly decreased bilaterally over the supraorbital, infraorbital, mental, median, ulnar and radial nerve trunks, C5-C6 joint, second metacarpal, and tibialis anterior muscles in patients with MS compared with pain-free controls (all, P<0.001). No significant differences existed between MS patients with pain and those without pain (all P>0.944). Patients with pain exhibited higher fatigue and depression than those patients without pain (P<0.05). PPT was not associated with any clinical variable, that is, pain, depression, or fatigue., Conclusions: Our study found widespread pressure pain hyperalgesia in individuals with MS as compared with pain-free controls. No differences existed between MS patients with pain and those without pain in the presence of widespread pressure sensitivity. Current results suggest that MS is associated with sensory hyperexcitability of the central nervous system or dysfunction in endogenous pain modulatory systems.

Objective: To examine the relationship between knee pain, altered somatosensation, and self-reported instability in individuals with knee osteoarthrosis (OA) during a step-up-and-over task., Methods: Quantitative sensory testing, including mechanical detection threshold (MDT), allodynia, vibration perception threshold, and pressure pain threshold (PPT), was assessed in 16 individuals (mean age, 52 ± 7 y) with knee OA and in 16 age-matched and sex-matched controls. Pain intensity ratings and subjective reports of instability/buckling were recorded at rest and while performing a step-up task, and these findings were correlated with somatosensory measures., Results: In the OA group, all participants reported allodynia on MDT testing. Compared with healthy controls, MDT was significantly increased (P<0.001), and vibration perception threshold was increased (P=0.02) at the medial knee, indicating hypoesthesia. PPT was significantly decreased at the medial joint line (P=0.03) and 12 cm distal (P=0.02). Comparing participants with OA having severe versus mild radiographic changes, PPT was lower at the medial joint line (P<0.01) but not at 12 cm distal. Fourteen (87.5%) participants with knee OA reported pain and instability during the step task as compared with none or 1 (6%) of the controls. On the step task, longer duration of symptoms was associated with increased pain (P=0.02). A moderate correlation between greater self-reported instability and increased vibratory hypoesthesia at the knee (r=-0.633; P=0.01) was demonstrated, suggesting a potential relationship between somatosensory changes and functional deficits., Conclusions: Severe OA may result in both hyperalgesia and hypoesthesia at the affected knee. Perceived instability during functional tasks may be mediated in part by pain in individuals with knee OA.

Objective: To describe the prevalence and referred pain area of trigger points (TrPs) in blue-collar (manual) and white-collar (office) workers, and to analyze if the referred pain pattern elicited from TrPs completely reproduces the overall spontaneous pain pattern., Methods: Sixteen (62% women) blue-collar and 19 (75% women) white-collar workers were included in this study. TrPs in the temporalis, masseter, upper trapezius, sternocleidomastoid, splenius capitis, oblique capitis inferior, levator scapulae, scalene, pectoralis major, deltoid, infraspinatus, extensor carpi radialis brevis and longus, extensor digitorum communis, and supinator muscles were examined bilaterally (hyper-sensible tender spot within a palpable taut band, local twitch response with snapping palpation, and elicited referred pain pattern with palpation) by experienced assessors blinded to the participants' condition. TrPs were considered active when the local and referred pain reproduced any symptom and the patient recognized the pain as familiar. The referred pain areas were drawn on anatomic maps, digitized, and measured., Results: Blue-collar workers had a mean of 6 (SD: 3) active and 10 (SD: 5) latent TrPs, whereas white-collar workers had a mean of 6 (SD: 4) active and 11 (SD: 6) latent TrPs (P>0.548). No significant differences in the distribution of active and latent TrPs in the analyzed muscles between groups were found. Active TrPs in the upper trapezius, infraspinatus, levator scapulae, and extensor carpi radialis brevis muscles were the most prevalent in both groups. Significant differences in referred pain areas between muscles (P<0.001) were found; pectoralis major, infraspinatus, upper trapezius, and scalene muscles showed the largest referred pain areas (P<0.01), whereas the temporalis, masseter, and splenius capitis muscles showed the smallest (P<0.05). The combination of the referred pain from TrPs reproduced the overall clinical pain area in all participants., Conclusions: Blue-collar and white-collar workers exhibited a similar number of TrPs in the upper quadrant musculature. The referred pain elicited by active TrPs reproduced the overall pain pattern. The distribution of TrPs was not significantly different between groups. Clinicians should examine for the presence of muscle TrPs in blue-collar and white-collar workers.

Objective: To evaluate the effects of an 8-week multidimensional physical therapy program, including strengthening exercises and recovery massage, on neck and shoulder pain, pressure hypersensitivity, and the presence of active trigger points (TrPs) in breast cancer survivors., Methods: In this randomized controlled clinical trial, 44 breast cancer survivors were randomly assigned into 2 groups: CUIDATE group who received a multidimensional physical therapy program; or CONTROL group who received usual care treatment for breast cancer. CUIDATE program consisted of 24 hours of individual physical training (aerobic, mobility, stretching, and strengthening exercises) and 12 hours of physical therapy recovery (stretching, massage) interventions (3 times/wk, 90 min). Outcomes included neck and shoulder pain (visual analog scale, 0 to 100), pressure pain thresholds over the C5-C6 zygapophyseal joints, deltoid muscles, second metacarpal and tibialis anterior muscles, and the presence of active TrPs in shoulder muscles. Outcomes were assessed at baseline and after the 8-week program by a blinded assessor., Results: The CUIDATE group showed an estimated improvement for neck pain of -56 mm [95% confidence interval (CI), -71--40, P<0.001; effect size 2.72, 1.94 to 3.44] and for shoulder/axillary of -56 mm (95% CI, -74--38, P<0.001; effect size 2.45, 1.66 to 3.23). Improvements were also noted for pressure pain thresholds levels: C5-C6 zygapophyseal joints (between-group differences 101 kPa, 95% CI, 60-143; effect size 1.68, 1.00 to 2.35; 92 kPa 55 to 129; d: 1.98, 1.18 to 2.77), deltoid muscles (98 kPa, 45 to 149; d: 1.34, 0.62 to 2.04; 75 kPa 18 to 132; d: 1.12, 0.27 to 1.96), second metacarpal (93 kPa, 45 to 134; d: 1.30, 0.63 to 1.86; 99 kPa 59 to 139; d: 1.60, 0.96 to 2.24), and tibialis anterior muscles (71 kPa, 40 to 144; d: 1.16, 0.65 to 2.34; 118 kPa 57 to 178; d: 1.17, 0.56 to 1.77). Finally, patients within the CUIDATE program showed a greater reduction of active muscle TrPs compared with the CONTROL group (P<0.01)., Conclusions: An 8-week multidimensional program including strengthening exercises, and massage as major components was effective for improving neck and shoulder pain and reducing widespread pressure hyperalgesia in breast cancer survivors compared with usual care treatment.

Objective: To determine the differences in widespread pressure pain and thermal hypersensitivity in women with minimal, moderate, and severe carpal tunnel syndrome (CTS) and healthy controls., Methods: A total of 72 women with CTS (19 with minimal, 18 with moderate, and 35 with severe) and 19 healthy age-matched women participated. Pressure pain thresholds were bilaterally assessed over the median, ulnar, and radial nerves, the C5 to C6 zygapophyseal joint, the carpal tunnel, and the tibialis anterior muscle. In addition, warm and cold detection thresholds and heat and cold pain thresholds were bilaterally assessed over the carpal tunnel and the thenar eminence. All outcome parameters were assessed by an assessor blinded to the participant's condition., Results: No significant differences in pain parameters among patients with minimal, moderate, and severe CTS were found. The results showed that PPT were significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the carpal tunnel, C5 to C6 zygapophyseal joint, and the tibialis anterior muscle in patients with minimal, moderate, or severe CTS as compared with healthy controls (all, P<0.001). In addition, patients with CTS also showed lower heat pain threshold and reduced cold pain threshold compared with controls (P<0.001). No significant sensory differences between minimal, moderate, or severe CTS were found., Conclusions: The similar widespread pressure and thermal hypersensitivity in patients with minimal, moderate, or severe CTS and pain intensity suggests that increased pain sensitivity is not related to electrodiagnostic findings.

Objectives: To determine whether the local and referred pain from active myofascial trigger points (MTrPs) reproduce the overall spontaneous fibromyalgia syndrome (FMS) pain pattern and whether widespread pressure hypersensitivity is related to the presence of widespread active MTrPs in FMS., Methods: Forty-four women with FMS (mean age: 47±8 y) and 50 comparable healthy women (age: 48±7 y) participated in the study. MTrPs in the temporalis, masseter, upper trapezius, splenius capitis, sternocleidomastoid, suboccipital, levator scapulae, scalene, pectoralis major, extensor carpi radialis brevis, extensor digitorum communis, gluteus maximus, piriformis, vastus medialis, and tibialis anterior muscles were explored. Pressure pain thresholds over 18 tender points specified in the 1990 American College of Rheumatology for FMS were also assessed by an assessor blinded to the condition of the participants., Results: The mean±SD number of MTrPs for each woman with FMS was 11±3, of which 10±2 were active MTrPs and the remaining 1±1 were latent. Healthy controls only had latent MTrPs (mean±SD: 2±1). The combination of the referred pain patterns from active MTrPs fully reproduced the overall spontaneous clinical pain area in patients with FMS. Patients with FMS had significant lower PPT compared with controls (P<0.001). Within FMS, a significant positive correlation was found between the number of active MTrPs and spontaneous pain intensity (rs=0.455; P=0.002)., Conclusions: The local and referred pain elicited from widespread active MTrPs fully reproduced the overall spontaneous clinical pain area in patients with FMS. Widespread mechanical pain hypersensitivity was related to a greater number of active MTrPs. This study suggests that nociceptive inputs from active MTrPs may contribute to central sensitization in FMS.

Objective: To describe the presence of widespread pressure pain hyperalgesia and myofascial trigger points (TrPs) in neck and shoulder muscles in patients with postmastectomy pain., Methods: Twenty-nine women (mean age: 50±8 y) with postmastectomy pain and 23 matched healthy controls (mean age: 50±9 y) participated. Pressure pain thresholds (PPT) were bilaterally assessed over the C5-C6 zygapophyseal joint, the deltoid muscle, the second metacarpal, and the tibialis anterior muscle. TrPs in the upper trapezius, suboccipital, levator scapulae, sternocleidomastoid, scalene, infraspinatus, and pectoralis major muscles were explored. TrPs were considered active if the local and referred pain reproduced symptoms and the patient recognized the pain as familiar., Results: Twenty-five (86%) patients reported neck pain whereas 20 (69%) patients showed shoulder/axillary pain. The results showed that PPT levels were significantly decreased bilaterally over the C5-C6 zygapophyseal joint, deltoid muscle, second metacarpal, and tibialis anterior muscle in patients with postmastectomy pain as compared with controls (all sites, P<0.001). No significant differences in the magnitude of PPT decrease between sites were found (P=0.222). The mean number of active TrPs for each woman with postmastectomy pain was 5.4±1.8. Healthy controls only had latent TrPs (0.5±0.6). Patients with postmastectomy pain showed a greater number of TrPs than controls (P<0.001). In all muscles, there was significantly more active TrPs in patients with postmastectomy pain as compared with controls (P<0.001). Active TrPs in the pectoralis major (n=27, 93%), infraspinatus (n=23, 79%), and upper trapezius (n=19, 65%) muscles were the most prevalent in the affected side in the postmastectomy group. The number of active TrPs was positively correlated with neck (rs=0.392, P=0.036) and shoulder/axillary (rs=0.437, P=0.018) pain intensity., Conclusions: Our findings revealed bilateral widespread pressure pain hypersensitivity in patients with postmastectomy pain. In addition, the local and referred pain elicited by active TrPs reproduced neck and shoulder/axillary complaints in these patients. These results suggest peripheral and central sensitization in patients with postmastectomy pain.

Objective: To investigate the changes in surface and intramuscular electromyographic (EMG) activity at latent trigger points (TrPs) in the extensor carpi radialis brevis muscle after injection of either glutamate or isotonic saline into latent TrPs in the infraspinatus muscle., Method: Nociceptive muscle stimulation was obtained by a bolus injection of glutamate (0.2 mL, 0.5 M) into a latent TrP located in the right infraspinatus muscle in 12 healthy volunteers. A bolus of isotonic saline (0.9%, 0.2 mL) injection served as control. Injections were guided by intramuscular EMG showing resting spontaneous electrical activity at the latent myofascial TrP in the infraspinatus muscle. Intramuscular (at the TrP) and surface EMG activities of both infraspinatus and extensor carpi radialis brevis muscles were recorded before, during, and after injection for a period of 6 minutes to monitor changes produced in EMG activity., Results: Glutamate injection into latent TrPs induced higher pain intensity than isotonic saline injection (P<0.001). The analysis of variance showed a significant increase in root mean square score of intramuscular EMG activity at TrP in the extensor carpi radialis brevis after glutamate (mean+/-SD: 212.0+/-215.6 microV) but not isotonic saline (mean+/-SD: 74.2+/-72.2 microV) injections (P<0.001). No changes in surface EMG activity were found. No significant changes in root mean square of intramuscular and surface EMG activity in the infraspinatus muscle were found., Conclusions: Our results show that an increased nociceptive activity at latent TrPs in the infraspinatus muscle may increase motor activity and sensitivity of a TrP in distant muscles at a same segmental level.

Objective: The aim of this study was to investigate whether generalized deep tissue hyperalgesia exists in patients with chronic unilateral lateral epicondylalgia (LE)., Methods: A total of 26 LE patients (10 males and 16 females, aged 25 to 63 y) and 20 healthy comparable matched controls (aged 26 to 61 y) were recruited and pressure pain threshold (PPT) was assessed bilaterally over the median, ulnar, and radial nerve trunks, the lateral epicondyle, C5-C6 zygapophyseal joint, and the tibialis anterior muscle in a blind design., Results: PPT was significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the lateral epicondyle, the C5-C6 zygapophyseal joint, and tibialis anterior muscle in patients with LE than healthy controls (all P<0.001). PPTs over those measured points was negatively related to current elbow pain intensity (all P<0.05). A more significant decrease in PPTs were present in females (all P<0.05)., Conclusions: This revealed a widespread mechanical hypersensitivity in patients with LE, which suggest that central sensitization mechanisms are involved in patients with unilateral LE. The generalized decrease in PPT levels was associated with elbow pain intensity, supporting a role of peripheral sensitization mechanisms in the initiation or maintenance of central sensitization mechanisms. In addition, females may be more prone to the development of generalized mechanical hypersensitivity.

Objective: To describe the common locations of active trigger points (TrPs) in the temporalis muscle and their referred pain patterns in chronic tension type headache (CTTH), and to determine if pressure sensitivity maps of this muscle can be used to describe the spatial distribution of active TrPs., Methods: Forty women with CTTH were included. An electronic pressure algometer was used to assess pressure pain thresholds (PPT) from 9 points over each temporalis muscle: 3 points in the anterior, medial and posterior part, respectively. Both muscles were examined for the presence of active TrPs over each of the 9 points. The referred pain pattern of each active TrP was assessed., Results: Two-way analysis of variance detected significant differences in mean PPT levels between the measurement points (F=30.3; P<0.001), but not between sides (F=2.1; P=0.2). PPT scores decreased from the posterior to the anterior column (P<0.001). No differences were found in the number of active TrPs (F=0.3; P=0.9) between the dominant side the nondominant side. Significant differences were found in the distribution of the active TrPs (chi2=12.2; P<0.001): active TrPs were mostly found in the anterior column and in the middle of the muscle belly. The analysis of variance did not detect significant differences in the referred pain pattern between active TrPs (F=1.1, P=0.4). The topographical pressure pain sensitivity maps showed the distinct distribution of the TrPs indicated by locations with low PPTs., Conclusions: Multiple active TrPs in the temporalis muscle were found, particularly in the anterior column and in the middle of the muscle belly. Bilateral posterior to anterior decreased distribution of PPTs in the temporalis muscle in women with CTTH was found. The locations of active TrPs in the temporalis muscle corresponded well to the muscle areas with lower PPT, supporting the relationship between multiple active muscle TrPs and topographical pressure sensitivity maps in the temporalis muscle in women with CTTH.

Objective: No study has previously analyzed pressure pain sensitivity of nerve trunks in migraine. This study aimed to examine the differences in mechanical pain sensitivity over specific nerves between patients with unilateral migraine and healthy controls., Methods: Blinded investigators assessed pressure pain thresholds (PPT) over the supra-orbital nerves (V1) and peripheral nerve trunks of both upper extremities (median, radial, and ulnar nerves) in 20 patients with strictly unilateral migraine and 20 healthy matched controls. Pain intensity after palpation over both supra-orbital nerves was also assessed. A pressure algometer was used to quantify PPT, whereas a 10-point numerical pain rate scale was used to evaluate pain to palpation over the supra-orbital nerve., Results: The analysis of covariance revealed that pain to palpation over the supra-orbital nerve was significantly higher (P<0.001) on the symptomatic side (mean: 3.4, SD: 1.5) as compared with the nonsymptomatic side (mean: 0.5, SD: 1.2) in patients with migraine and both the dominant (mean: 0.2, SD: 0.4) and nondominant (mean: 0.3, SD: 0.5) sides in healthy controls. PPT assessed over the supra-orbital nerve on the symptomatic side (mean: 1.05, SD: 0.2 kg/cm) was significantly lower (P<0.05) than PPT measurements on the nonsymptomatic side (mean: 1.35, SD: 0.3 kg/cm) and either the dominant (mean: 1.9, SD: 0.2 kg/cm) or nondominant (mean: 1.9, SD: 0.3 kg/cm) sides in controls (P<0.001). Finally, PPT assessed over the median, ulnar, and radial nerves were significantly lower in patients with migraine as compared with controls (P<0.001), without side-to-side differences (P>0.6)., Conclusions: In patients with unilateral migraine, we found increased mechano-sensitivity of the supra-orbital nerve on the symptomatic side of the head. Outside the head, the same patients showed increased mechano-sensitivity of the main peripheral nerves of both upper limbs, without asymmetries. Such diffuse hypersensitivity of the peripheral nerves lends further evidence to the presence of a state of hyperexcitability of the central nervous system in patients with unilateral migraine.

Objective: The aim of the present study was to investigate the presence of active and latent muscle trigger points (TrPs) in the forearm musculature on both affected and unaffected sides in patients with lateral epicondylalgia (LE) and healthy controls., Methods: Twenty-five patients with LE and 20 healthy matched controls participated. Both groups were examined for the presence of TrPs in the extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis, and brachioradialis muscles in a blinded fashion. TrPs were identified in both affected and unaffected sides within the patient group. In the control group, TrPs were explored around the dominant side. Pressure pain thresholds (PPTs) were assessed on both affected and unaffected arms., Results: In the patient group, the number of active muscle TrPs in the affected side was 3.1 [95% confidence interval (CI): 2.8-3.4], whereas in the unaffected arm, only latent TrPs were found (mean: 2.2; 95% CI: 1.8-2.6). Active TrPs were only located on the affected side (P<0.001). Within the control group, the number of latent TrPs in the dominant arm was 0.4 (95% CI: 0.0-0.7), which was significantly lower than the number of latent TrPs in the unaffected arm (P<0.001) in patients. Therefore, latent muscle TrPs in the forearm musculature were associated with the unaffected side in the patient group as compared with the dominant arm in healthy controls: extensor carpi radialis brevis [odds ratio (OR)=66 (95% CI: 9.9-48.8)], extensor carpi radialis longus [OR=16 (95% CI: 3.7-29.6)], brachioradialis [OR=2.6 (95% CI: 0.3-27.1)], and extensor digitorum communis [OR=0.5 (95% CI: 0.4-0.8)]. PPTs were lower around the affected side than around the unaffected arm in patients (mean+/-SD: 274.5+/-90.4 KPa vs. 465.4+/-140.7 KPa; P<0.001) in the patient group. Finally, PPT from the extensor digitorum muscle in those patients with active TrPs (mean+/-SD: 244+/-70.4 KPa) was significantly lower (P<0.001) than PPT levels of patients with no TrP in the same muscle (mean+/-SD: 370+/-83.4 KPa)., Conclusions: Latent TrPs are present in forearm muscles on the unaffected side in patients with LE where active TrPs contribute to the pain on the affected arm. The presence of latent TrPs on the unaffected side in unilateral LE may be related to central sensitization and be a mechanism explaining bilateral pain in some patients with unilateral pathologies.

Objective: To assess the local and referred pain areas and pain characteristics evoked from temporalis muscle trigger points (TrPs) in chronic tension-type headache (CTTH)., Methods: Thirty CTTH patients and 30 age and sex-matched controls were studied. A headache diary was kept for 4 weeks to substantiate the diagnosis and record the pain history. Both temporalis muscles were examined for the presence of myofascial TrPs in a blinded fashion. The local and referred pain intensities, referred pain pattern, and pressure pain threshold were recorded., Results: Referred pain was evoked in 87% and 54% on the dominant and nondominant sides in CTTH patients, which was significantly higher (P<0.001) than in controls (10% vs. 17%, respectively). Referred pain spread to the temple ipsilateral to the stimulated muscle in both patients and controls, with additional referral behind the eyes in most patients, but none in controls. CTTH patients reported a higher local [visual analog scale (VAS): 5.6+/-1.2 right side, 5.3+/-1.4 left side] and referred pain (VAS: 4.7+/-2 right side, 3.5+/-2.8 left side) intensity than healthy controls (VAS: 0.8+/-0.7 right side, 0.7+/-0.7 left side for local pain; and 0.3+/-0.2 right side, 0.4+/-0.3 left side for referred pain) in both temporalis muscles (both, P<0.001). The local and referred pain areas were larger in patients than in controls (P<0.001). Twenty-three out of 30 CTTH patients (77%) had active TrPs in the temporalis muscle leading to their usual headache (17 patients on the right side; 12 on the left side, whereas 6 with bilateral active TrPs). CTTH patients with active TrPs in either right or left temporalis muscle showed longer headache duration than those with latent TrPs (P=0.004). CTTH patients showed significantly (P<0.001) lower pressure pain threshold (1.1+/-0.2 right side, 1.2+/-0.3 left side) as compared with controls (2.5+/-0.5 right side, 2.6+/-0.4 left side)., Conclusions: In CTTH patients, the evoked local and referred pain from active TrPs in the temporalis muscle and its sensory characteristics shared similar patterns as their habitual headache pain. Local and referred pain from active TrPs in the temporalis muscles may constitute one of the sources contributing to the pain profile of CTTH.

Objective: The aim was to investigate whether increased pericranial tenderness or decreased pressure pain threshold (PPT) was related to headache intensity, duration, and frequency in chronic tension-type headache (CTTH)., Methods: Twenty-five CTTH patients and 25 matched controls were studied. A headache diary was kept for 4 weeks to substantiate the diagnosis and record the pain history. Three tenderness (total, cephalic, and neck) scores and PPT at both cephalic and neck points were objectively and blinded assessed. Bodily pain perceived by the patients was assessed with the Short Form-36 questionnaire., Results: CTTH patients showed decreased PPT and increased tenderness as compared with controls (P<0.001). Negative correlations were found between PPT on each point and their respective tenderness scores. Within the CTTH group, neither increased tenderness nor decreased PPT seemed to directly influence headache intensity, frequency or duration; or vice versa., Discussion: Increased tenderness may predispose the patients to other perpetuating factors in inducing headache attacks. Further research is needed to clearly define the role of pericranial tender tissues or other factors in the genesis and maintenance of CTTH.

Objective: Referred pain and pain characteristics evoked from the extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis, and brachioradialis muscles was investigated in 20 patients with lateral epicondylalgia (LE) and 20-matched controls., Methods: Both groups were examined for the presence of myofascial trigger points (TrPs) in a blinded fashion. The quality and location of the evoked referred pain, and the pressure pain threshold (PPT) at the lateral epicondyle on the right upper extremity (symptomatic side in patients, and dominant-side on controls) were recorded. Several lateral elbow pain parameters were also evaluated., Results: Within the patient group, the elicited referred pain by manual exploration of 13 out of 20 (65%) extensor carpi radialis brevis muscles, 12/20 (70%) extensor carpi radialis longus muscles, 10/20 (50%) brachioradialis muscles, and 5/20 (25%) extensor digitorum communis muscles, shares similar pain patterns as their habitual lateral elbow and forearm pain. The mean number of muscles with TrPs for each patient was 2.9 [95% confidence interval (CI) 1,4] of which 2 (95% CI 1,3) were active, and 0.9 (95% CI 0,2) were latent TrPs. Control participants only had latent TrPs (mean: 0.4; 95% CI 0,2). TrP occurrence between the 2 groups was significantly different for active TrPs (P<0.001), but not for latent TrPs (P>0.05). The referred pain pattern was larger in patients than in controls, with pain referral to the lateral epicondyle (proximally) and to the dorso-lateral aspect of the forearm in the patients, and confined to the dorso-lateral aspect of the forearm in the controls. Patients with LE showed a significant (P<0.001) lower PPT (mean: 2.1 kg/cm; 95% CI 0.8, 4 kg/cm) as compared with controls (mean: 4.5 kg/cm; 95% CI 3, 7 kg/cm). Within the patient group, PPT at the lateral epicondyle was negatively correlated with both the total number of TrPs (rs=-0.63; P=0.003) and the number of active TrPs (rs=-0.5; P=0.02): the greater the number of active TrPs, the lower the PPT at the lateral epicondyle., Discussion: Our results suggest that in patients with LE, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual elbow and forearm pain, consistent with active TrPs. Lower PPT and larger referred pain patterns suggest that peripheral and central sensitization exists in LE.

Objective: Some patients with trochlear disorders have been found to suffer from concurrent migraine. However, a trochlear examination is not systematically done in patients with migraine. Moreover, a search for myofascial trigger points in the superior oblique muscle has never been reported in these patients., Methods: The trochlear region was examined in 20 participants with strictly unilateral migraine without side-shift and in 20 controls. Referred pain elicited by different maneuvers during manual palpation (ie, maintained pressure, active muscle contraction, and stretching of the superior oblique muscle) was assessed with a visual analog scale. All participants were headache free on the day of evaluation., Results: Sixteen participants with migraine (80%) perceived referred pain on examination of the trochlear area. It was described as a tightening sensation in the retro-orbital region, sometimes extending to the supraorbital region and the homolateral forehead. In 15 participants with migraine, both the active contraction and the stretching of the muscle increased the referred pain, which was consistent with definite myofascial trigger points. All the definite trigger points were ipsilateral to the side of the headache. Conversely, only 5 controls (20%) had referred pain. None of them had definite myofascial trigger points because muscle stretching did not increase the intensity of pain. The intensity of referred pain at each stage of the trochlear examination was greater in subjects with migraine than in controls (P<0.001)., Conclusion: Patients with unilateral migraine commonly perceive referred pain from the trochlear area that probably comes from the myofascial trigger points. Myofascial disorders in the trochlear region might contribute to the perpetuation of concomitant migraine.

Objectives: A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH)., Methods: Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence., Results: Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3)., Conclusions: The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.