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Introduction: Ultrasound guided-percutaneous electrical nerve stimulation appears to be effective in the treatment of chronic musculoskeletal pain., Objective: To investigate the immediate effects of one session of percutaneous electrical nerve stimulation on the radial nerve in patients with lateral elbow pain., Methods: A randomized clinical trial was conducted. Sixty patients with chronic lateral elbow pain were allocated into real-percutaneous electrical nerve stimulation ( n  = 30) or sham-percutaneous electrical nerve stimulation ( n  = 30) where the patients received one-single session of the real or sham percutaneous stimulation on the radial nerve, respectively. Pressure pain thresholds, pain intensity, pain-free grip strength, and the self-perceived improvement were evaluated after the intervention., Results: Significant differences between groups for pain intensity (-11.55, 95% CI -21.79 to -1.30, p  < .028), but not for pressure pain threshold or pain-free grip strength, were found. Patients receiving real-percutaneous stimulation had significant improvement in pain-free grip strength on the treated side. The proportion of individuals reporting moderate to large self-perceived improvement (≥4) was significantly higher ( p  = .026) after real-percutaneous stimulation than after sham-percutaneous stimulation., Conclusion: A single session of real-percutaneous electrical nerve stimulation targeting the radial nerve in subjects with lateral elbow pain decreased pain intensity between groups and increased pain-free grip strength on the treated side but not between groups.

Objectives: We evaluate the presence of sensitization-associated symptoms and neuropathic pain features and identify if there is an association between these symptoms and pressure pain sensitivity, pain, and related-disability in lateral elbow tendinopathy., Methods: Thirty-seven (43% women, age: 45.5 ± 9.5 years) patients with lateral elbow tendinopathy completed: demographic (i.e. age, height, and weight); clinical (i.e. pain history, pain intensity, and Disabilities of the Arm, Shoulder and Hand); and psychophysical (i.e. pressure pain thresholds at the elbow, cervical spine, hand, and leg) outcomes, and the Central Sensitization Inventory and Self-administered Leeds Assessment of Neuropathic Symptoms and Signs questionnaires. Step-wise multiple linear regression models were performed to identify predictors of sensitization- or neuropathic-associated symptoms., Results: Six (16%) patients exhibited sensitization-associated symptoms (mean: 46.5, SD: 6.1), whereas 13 (35%) patients showed neuropathic-associated symptoms (mean: 13.5; SD: 1.4). Sensitization-associated symptoms were positively associated with neuropathic-associated symptoms ( r  = 0.538, P  = .001) and negatively associated with pressure pain thresholds at the leg ( r  = -0.378, P  = .021). Neuropathic-associated symptoms were positively associated with related-disability ( r  = 0.479, P  = .003) and negatively associated with pressure pain threshold at the elbow ( r  = -0.394, P  = .017). Stepwise regression analyses revealed that neuropathic-like symptoms explained 26.8% of the variance of sensitization symptoms (r 2 : 0.268), whereas pressure pain threshold at the elbow explained an additional 6.6% to neuropathic-like symptoms (r 2 : 0.334)., Conclusion: This explorative study identified sensitization- and neuropathic-associated symptoms in 16% and 35% of the people with lateral elbow tendinopathy. Sensitization- and neuropathic-associated symptoms were associated. Pressure pain sensitivity at the elbow (peripheral sensitization) was associated with neuropathic -associated symptoms.

Objective: The aims of the current study were to investigate the presence of widespread pressure hyperalgesia, the presence of structural changes in the wrist extensor tendon and muscle, and their association in people with lateral epicondylalgia (LE)., Methods: Thirty-seven patients with LE (43% women; mean age = 45.5 [SD = 9.5] years) and 37 controls matched for age and sex and free of pain participated in this study. Pressure pain thresholds (PPTs) were assessed bilaterally over the symptomatic area (elbow), 2 segment-related areas (C5-C6 joint, second intermetacarpal space), and 1 remote area (tibialis anterior) in a blinded design. Ultrasound measurements (eg, cross-sectional area, thickness, and width) of the common wrist extensor tendon and extensor carpi radialis brevis muscle as well as the thickness of the supinator muscle were assessed., Results: Patients with LE exhibited lower PPTs bilaterally at all points and lower PPTs at the lateral epicondyle and second intermetacarpal space on the symptomatic side as compared to the nonsymptomatic side (η2 from 0.123-0.369; large effects). Patients exhibited higher cross-sectional area and width of the common wrist extensor tendon (η2 from 0.268-0.311; large effects) than controls bilaterally, whereas tendon thickness was also higher (η2 = 0.039; small effects) on the painful side than on the nonpainful side., Conclusions: This study reported bilateral widespread pressure pain hyperalgesia and morphological changes in the tendon, but not the muscle, in LE. Pressure pain sensitivity and morphological changes were not associated in individuals with LE., Impact: Management of LE should consider altered nociceptive pain processing and structural tendon changes as 2 different phenomena in patients with LE., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The nociceptive pain processing of soft-tissue overuse conditions is under debate because no consensus currently exists. The purpose of this meta-analysis was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas in 2 groups: participants with symptomatic lower extremity overuse soft-tissue conditions and controls who were pain free., Methods: Five databases were searched from inception to December 1, 2021, for case-control studies comparing PPTs between individuals presenting with symptomatic lower extremity tendinopathy/overuse injury and controls who were pain free. Data extraction included population, diagnosis, sample size, outcome, type of algometer, and results. The methodological quality (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development, and Evaluation) were assessed. Meta-analyses of symptomatic, segmental related, and distant pain-free areas were compared., Results: After screening 730 titles and abstracts, a total of 19 studies evaluating lower extremity overuse conditions (Achilles or patellar tendinopathy, greater trochanteric pain syndrome, plantar fasciitis, and iliotibial band syndrome) were included. The methodological quality ranged from fair (32%) to good (68%). Participants with lower extremity overuse injury had lower PPTs in both the painful and nonpainful areas, mirrored test-site, compared with controls (affected side: mean difference [MD] = -262.92 kPa, 95% CI = 323.78 to -202.05 kPa; nonaffected side: MD = -216.47 kPa, 95% CI = -304.99 to -127.95 kPa). Furthermore, people with plantar fasciitis showed reduced PPTs in the affected and nonaffected sides at segmental-related (MD = -176.39 kPa, 95% CI = -306.11 to -46.68 kPa) and distant pain-free (MD = -97.27 kPa, 95% CI = 133.21 to -61.33 kPa) areas compared with controls., Conclusion: Low- to moderate-quality evidence suggests a reduction of PPTs at the symptomatic area and a contralateral/mirror side in lower extremity tendinopathies and overuse conditions compared with pain-free controls, particularly in plantar fasciitis and greater trochanteric pain syndrome. Participants with plantar fasciitis showed a reduction of PPTs on the affected and non-affected sides at a segmental-related area (very low-quality evidence) and at a remote asymptomatic area (moderate-quality evidence)., Impact: Some overuse peripheral pain conditions may be more associated with pressure pain sensitivity than others. Accordingly, examination and identification of conditions more peripherally, centrally, or mixed mediated could potentially lead to more specific and different treatment strategies., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Sensitization mechanisms are thought to play a role in the perception of pain in people with cluster headache. No study has investigated the relation between the spatial extent of pain in cluster headache and measures of sensitization or other clinical features., Objective: Our aim was to investigate if the size of the painful area in people with cluster headache relates to widespread pressure sensitivity, headache features, and psychological outcomes., Methods: Forty men with episodic cluster headache reported their symptoms on a digital body chart and pain extent was calculated. Pressure pain thresholds were assessed locally over the temporalis muscle and the C5-C6 joint and at a remote site over the tibialis anterior to assess widespread pressure sensitivity. Clinical features of headache attacks, and anxiety/depressive levels were also assessed. Patients were assessed during a period of remission 6 months after their last pain attack and after treatment discontinuation., Results: Thirty-two (80%) and thirty (75%) patients reported their headaches in the orbital and the frontal areas, respectively. No significant associations (rho values ranging from -0.228 to 0.187, P values ranging from 0.157 to 0.861) were found between pain extent and pressure pain thresholds in trigeminal, extra-trigeminal, and distant pain-free areas, headache clinical features, and anxiety and depressive levels., Conclusion: Pain extent in the trigemino-cervical area was not related to the degree of pressure pain sensitivity or headache features in men with episodic cluster headache during a period of remission.

Objective: To assess the effects of adding a neurodynamic intervention into a multimodal management approach in individuals with multiple sclerosis (MS) with upper extremity pain symptoms., Design: Randomized clinical trial., Setting: Tertiary hospital center., Participants: Thirty-two individuals with MS were randomly assigned to multimodal usual care alone (n=16) or multimodal usual care plus neurodynamic intervention (n=16)., Interventions: Both groups received 5 sessions of multimodal usual care of 30minutes duration, twice per week. Subjects allocated to the neurodynamic group also received bilateral neurodynamic slider interventions targeting the upper extremity nerve trunks., Outcome Measures: Pressure pain thresholds (PPTs) at the radial, median and ulnar nerve trunks, second metacarpal and tibialis anterior, pain intensity in the upper extremity (NPRS, 0-10), light touch detection threshold (von Frey hairs) and manual dexterity (nine-hole peg test) were assessed before and after the intervention., Results: Subjects receiving the neurodynamic interventions experienced larger improvements in PPTs at all locations (moderate effect size, between-groups differences from 89.5 to 186.5kPa), a higher decrease in pain intensity at rest (large effect, difference 1.7, 95%CI 0.4 to 3.0) and improvements in sensitivity to light touch (moderate effect, difference -0.7, 95%CI -1.3 to -0.1) and in manual dexterity (large effect, difference 7.7, 95%CI 4.0 to 11.4seconds) than those that did not receive the neurodynamic intervention., Conclusions: The inclusion of neural mobilization into a multimodal management approach resulted in reduction of pressure sensitivity, greater reduction in pain and improvement in sensitivity to light touch and manual dexterity in MS. Further studies are necessary to confirm these findings at longer term follow-ups. (ClinicalTrials.gov: NCT03595631)., (Copyright © 2022 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objective: The presence of altered nociceptive pain processing in patients with upper extremity tendinopathy/overuse injury is conflicting. Our aim was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas between patients with upper extremity tendinopathy/overuse injury and controls., Methods: Five databases were searched from inception to October 15, 2020. The authors selected case-control studies comparing PPTs between individuals with upper extremity tendinopathy/overuse injury and pain-free controls. Data were extracted for population, diagnosis, sample size, outcome, and type of algometer. Results were extracted by 3 reviewers. The methodological quality/risk of bias (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development and Evaluation approach) were assessed. Meta-analyses of symptomatic, segment-related, and distant pain-free areas were compared., Results: The search identified 807 publications with 19 studies (6 shoulder, 13 elbow) eligible for inclusion. The methodological quality ranged from fair (48%) to good (37%). Patients exhibited lower bilateral PPTs than controls at the symptomatic area (affected side: MD = -175.89 kPa [95% CI = -220.30 to -131.48 kPa]; nonaffected side: MD = -104.50 kPa [95% CI = -142.72 to -66.28 kPa]) and the segment-related area (affected side: MD = -150.63 kPa [95% CI = -212.05 to -89.21 kPa]; nonaffected side: MD = -170.34 kPa [95% CI = - 248.43 to -92.25]) than controls. No significant differences in PPTs over distant pain-free areas were observed., Conclusion: Low to moderate quality evidence suggests bilateral hypersensitivity to pressure pain at the symptomatic and contralateral/mirror areas in patients with upper extremity tendinopathies/overuse injury. Moderate quality of evidence supports bilateral pressure pain sensitivity in the segment-related area (neck) in lateral epicondylalgia, but not in subacromial impingement syndrome. No evidence of widespread pressure pain hyperalgesia was reported., Impact: Early identification of people with altered pain modulation could guide clinicians in treatment strategies. This review shows that there is a complex interplay between peripheral and central pain mechanisms in upper extremity tendinopathies/overuse injuries and that there likely are different subgroups of patients with upper extremity conditions., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: Previous studies reported the presence of widespread pressure pain sensitivity in patients with tension-type headache. However, most of the studies assessed pressure pain sensitivity over muscle tissue. Our aim was to investigate the difference in pressure pain sensitivity over musculoskeletal and nerve symptomatic and distant areas between women with frequent episodic tension-type headache (FETTH) and healthy subjects., Methods: Thirty-two women with FETTH and 32 matched healthy women participated. Pressure pain threshold (PPT) was bilaterally assessed over several nerve trunks (greater occipital, median, radial, ulnar, common peroneal, tibialis posterior) and musculoskeletal structures (temporalis muscle, C5/C6 joint, tibialis anterior) by an assessor blinded to the subject's condition. A four-week headache diary was used to collect the intensity, frequency, and duration of headache. The Hospital Anxiety and Depression Scale was used to determine anxiety and depressive levels., Results: Analysis of covariance found lower widespread and bilateral PPTs over all nerve trunks and musculoskeletal structures in women with FETTH pain (P < 0.001). No significant effect of anxiety and depressive levels on PPTs was found (all P > 0.222). PPT over the temporalis muscle was significantly negatively correlated with headache intensity., Conclusions: This study found widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures in women with FETTH, suggesting that the presence of central altered nociceptive processing is not just restricted to musculoskeletal areas, for example, muscles, but also pain evoked from directly provoking the nerve trunks by pressure. It is also possible that nerve tissue treatment could lead to a decrease in central sensitization and headache features., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We investigated if dynamic pressure pain sensitivity in the symptomatic area is associated with pressure sensitivity in local and distant pain-free areas in cluster headache (CH). A pressure algometry set consisting of 8 rollers with fixed pressure levels ranging from 500 to 5300 g was used to assess dynamic pressure pain sensitivity in men with episodic CH. Each roller was moved from an anterior-to-posterior direction over the temporalis muscle. The load level of the first painful roller was considered the dynamic pain threshold (DPT). Further, pain elicited during DPT (roller evoked pain) was also assessed. We used a pressure algometer to determine pressure pain thresholds (PPTs) over the temporalis muscle, C5/C6 joint, second metacarpal, and tibialis anterior. Patients were assessed in an asymptomatic (remission) phase, at least 6 months after their last cluster period and without taking pharmacological treatment. Forty men with episodic CH (mean age 42 years) were included. Both outcomes, DPTs (r = 0.781, P < 0.001) and roller-evoked pain (r = 0.586; P < 0.001) were bilaterally correlated. Further, DPT, but not roller-evoked pain, was moderately associated with PPTs measured at the symptomatic (temporalis: r = 0.665, P < 0.001) and distant pain-free (C5-C6 joint: r = 0.389, P = 0.013; second metacarpal: r = 0.551, P < 0.001; and, tibialis anterior: r = 0.308, P = 0.035) points. Dynamic pressure sensitivity in the trigeminal area was correlated to pressure pain sensitivity at both symptomatic and distant pain-free areas in men with CH supporting the use of roller pressure algometry. Dynamic pressure algometry may be a new tool for assessing the status of sensitization in primary headaches.

Objective: Pain is one of the most frequent nonmotor impairments in Parkinson's disease (PD) and is hypothesized to be associated with altered nociceptive pain processing. Our aims were to investigate differences in widespread pressure pain sensitivity between PD patients with and without pain and healthy controls and to assess the relationship of health-related quality of life and sleep quality with pressure pain sensitivity., Methods: Nineteen PD patients with pain (12 men, age = 68 ± 9 years), 19 PD patients without pain (11 men, age = 69 ± 8 years), and 19 matched controls participated. Pressure pain thresholds (PPTs) were assessed bilaterally over the cervical spine, the second metacarpal, and the tibialis anterior by an assessor blinded to the subject's condition. Patients were assessed in a dopamine-medicated (ON) state. Pain intensity (numerical pain rating scale, 0-10), health-related quality of life (39-item Parkinson's Disease Questionnaire), and sleep quality (Pittsburgh Sleep Quality Index) were also assessed., Results: No significant differences existed between PD patients, with or without pain, and healthy controls on PPTs over the cervical spine, the second metacarpal, or the tibialis anterior muscle (all P > 0.3). PPTs were lower in females than in males in all groups (P < 0.01). In PD patients with pain, worse quality of sleep was associated with higher widespread pressure pain sensitivity (-0.607 < r < -0.535, P < 0.05). No other significant association was observed., Conclusions: This study revealed no differences in widespread pressure hyperalgesia between PD patients with or without pain (ON state) and controls. Although dopamine may modulate pain responses, other mechanisms seems to also be implicated in altered nociceptive pain processing in patients with PD., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

(1) Background: Spatial changes in pressure sensitivity have been described in migraine and tension-type headaches. Our aim was to determine differences in the spatial distribution of pressure pain sensitivity of the temporalis muscle between cluster headache (CH) patients and headache-free controls; (2) Methods: Pressure pain thresholds (PPTs) were determined over nine points covering the temporalis muscle in 40 men with episodic CH and 40 matched headache-free controls in a blinded fashion. Topographical pressure pain sensitivity maps were constructed based on interpolation of the PPTs. Patients were evaluated in a pain-free period (remission phase), at least 3 months from the last attack and without medication; (3) Results: The analysis of covariance (ANCOVA) found significant difference between points (F = 21.887; P < 0.001) and groups (F = 24.416; P = 0.602), but not between sides (F = 0.440; P = 0.508). No effect of depression (F = 0.014; P = 0.907) or anxiety (F = 0.696; F = 0.407) was observed. A post-hoc analysis revealed: 1) lower PPTs at all points in patients than in controls, 2) an anterior-to-posterior gradient in patients but not in controls, with lower PPTs located in the anterior column. Large between-groups effects were shown in all points (standardized mean difference, SMD > 0.8); (4) Conclusions: Bilateral pressure pain hypersensitivity to pressure pain in the temporalis muscle and an anterior-to-posterior gradient to pressure pain was observed in men with episodic CH.

Objective: Chronic ankle instability (CAI) is reported after ankle sprain. Our aim was to assess differences in mechanical pain sensitivity of lower extremity nerve trunks and physical performance between amateur soccer players with and without CAI., Design: A cross-sectional case-control study., Setting: Amateur soccer teams., Participants: Fifty-five male soccer players, 28 with and 27 without CAI participated., Main Outcome Measures: The perceived instability was assessed with the Cumberland Ankle Instability Tool (CAIT). Pressure pain thresholds (PPTs) on the common peroneal and tibialis nerve trunks, vertical jump, lateral step-down test and joint position sense of the knee were assessed by a blinded assessor., Results: Soccer players with CAI showed lower PPTs over the common peroneal nerve than those without CAI (between-groups mean difference: 1.0 ± 0.8 kg/cm 2 , P < 0.001). No differences for PPT over the tibialis posterior (P = 0.078) or any physical performance outcome (knee joint positioning sense [P = 0.798], lateral step-down test [P = 0.580] and vertical jump variables [all, P > 0.310]) were found. PPT over the common peroneal nerve exhibited a significant moderate correlation with the CAIT score (r = 0.528, P < 0.001)., Conclusion: Amateur soccer players with CAI have higher pressure pain sensitivity over the common peroneal nerve but exhibit similar physical performance to amateur soccer players without CAI., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Plantar heel pain is one of the most common foot pain conditions treated by health care providers., Objectives: To investigate differences in topographical pressure pain sensitivity maps of the feet between patients with unilateral plantar heel pain and healthy individuals, and to determine the relationship between topographical pressure maps, pain intensity, disability, and fascia thickness., Methods: Thirty-five patients with unilateral plantar heel pain and 35 matched healthy controls participated in this cross-sectional, case-control study. Pressure pain thresholds (PPTs) were assessed over 7 plantar locations on each foot. Topographical pressure pain sensitivity maps of the plantar region were generated using the averaged PPT of each assessed point. Pain and related disability were assessed with a numeric pain-rating scale (0-10) and the Foot and Ankle Ability Measure, respectively. Plantar fascia thickness was measured via ultrasound. All outcomes were obtained by an assessor blinded to the participants' condition., Results: Topographical pressure sensitivity maps revealed lower bilateral PPTs in patients with plantar heel pain compared to healthy controls, and a higher PPT on the calcaneus bone ( P <.01). Women had lower PPTs than men in all areas ( P <.001). Individuals with plantar heel pain also had thicker fascia, but only on the affected side, compared to healthy controls. Higher pressure pain sensitivity in the foot was associated with higher pain intensity at first step in the morning and thicker fascia at the calcaneus bone., Conclusion: People with unilateral plantar heel pain had generalized bilateral pressure pain sensitivity in the plantar region of the foot. Greater pain intensity and fascia thickness were associated with higher pressure pain sensitivity in people with plantar heel pain., Level of Evidence: Case-control study, level 4. J Orthop Sports Phys Ther 2019;49(9):640-646. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8813 .

Objectives To explore the validity of the roller pressure algometer as a new tool for evaluating dynamic pressure sensitivity by assessing its association with pain features and widespread pressure pain sensitivity in migraine women, and also to determine whether dynamic pressure algometry differentiates between episodic and chronic migraine. Methods One hundred and twenty women with migraine (42% chronic, 58% episodic) participated. Dynamic pressure sensitivity was assessed with a set of roller pressure algometers (Aalborg University, Denmark®) consisting of 11 rollers with fixed pressure levels from 500 to 5300 g. Each roller was moved at a speed of 0.5 cm/sec over a 60 mm horizontal line covering the temporalis muscle. The dynamic pain threshold (the pressure level of the first painful roller) and pain elicited during the pain threshold (roller evoked pain) were determined. Static pressure pain thresholds were assessed over the temporalis muscle, C5/C6 joint, second metacarpal, and tibialis anterior. Results Side-to-side consistency between dynamic pain threshold (r s  = 0.769, p < 0.001) and roller evoked pain (r s  = 0.597; p < 0.001) were found. Women with chronic migraine exhibited bilateral lower dynamic pain thresholds ( p < 0.01), but similar widespread pressure pain thresholds (all, p > 0.284) than those with episodic migraine. Dynamic pain threshold was moderately positively associated with widespread pressure pain thresholds (0.358 > r s  > 0.700, all p < 0.001). This association was slightly stronger in chronic migraine. Pain during dynamic pain threshold was negatively associated with widespread pressure pain thresholds (-0.336 < r s  < -0.235, all p < 0.01). Conclusions Roller pressure algometry was valid for assessing dynamic pressure sensitivity in migraine in the trigeminal area and is consistent with widespread static pressure pain sensitivity. Roller, but not static, pressure algometry differentiated between episodic and chronic migraine. Assessing static and dynamic deep somatic tissue sensitivity may provide new opportunities for evaluating treatment outcomes.

Objective To investigate the association between trigger points (TrPs) and widespread pressure pain sensitivity in people with tension-type headache (TTH) and to determine if this association is different between frequent episodic (FETTH) or chronic (CTTH) headache. Design A cross-sectional study. Methods One hundred and fifty-seven individuals (29% male) with TTH participated. Clinical features of headache, i.e., intensity, duration, and frequency, were recorded in a headache diary. Active and latent TrPs were bilaterally explored in the temporalis, masseter, suboccipital, upper trapezius, sternocleidomastoid, and splenius capitis muscles. Pressure pain thresholds (PPT) were assessed over the trigeminal area (i.e., temporalis muscle), extra-trigeminal (i.e., C5/C6 zygapophyseal joint), and two distant pain-free points (i.e., second metacarpal and tibialis anterior muscle). Results Eighty (51%) patients were classified as FETTH, whereas 77 (49%) were classified as CTTH. No differences in the number of either active or latent TrPs (all p > 0.171) or widespread pressure pain sensitivity (all p > 0.351) were observed between FETTH and CTTH groups. The number of active and latent TrPs was significantly and negatively associated with PPTs: The higher the number of active or latent TrPs, the lower the widespread PPT, and the more generalized sensitization. This association was stronger within the FETTH group than the CTTH group. Conclusions This study found that the number of TrPs in head and neck/shoulder muscles was associated with widespread pressure hypersensitivity independently of the frequency of headache.

Objectives: To investigate the association between pain, disability, trigger points (TrPs), and pressure pain thresholds (PPTs) in patients with mechanical neck pain (MNP) or whiplash-associated disorders (WAD)., Materials and Methods: In total, 46 MNP and 51 WAD patients underwent a physical examination consisting of cervical range of motion, PPTs in the upper trapezius and tibialis anterior muscles, TrPs examination in the upper trapezius, and collection of clinical data including disability, pain intensity, and spontaneous symptomatic pain area., Results: A significantly moderate positive association between pain and disability was found in both groups (P<0.01). Significantly negative associations between pain intensity and PPT in the upper trapezius (P=0.008 and 0.041), pain and PPT in tibialis anterior (P=0.015 and 0.038), disability and PPT in upper trapezius (both, P=0.006) were also found in both MNP and WAD groups. Individuals with MNP showed significantly positive association between pain area and disability (P=0.034) and negative association between disability and PPT in the tibialis anterior (P=0.003). Patients with active TrPs in the upper trapezius exhibited higher intensity of neck pain, higher neck disability, and lower PPTs than those with latent TrPs in upper trapezius in both groups., Discussion: The association between pain, disability, and PPTs is common in patients with neck pain regardless of the origin of neck pain. The presence of active TrPs was related to higher pain intensity and related-disability and lower PPTs.

Background: Identification of subgroups of patients with different levels of sensitization and clinical features can help to identify groups at risk and the development of better therapeutic strategies. The aim of this study was to identify subgroups of patients with tension type headache (TTH) with different levels of sensitization, clinical pain features, and psychological outcomes., Methods: A total of 197 individuals with TTH participated. Headache intensity, frequency, and duration and medication intake were collected with a 4-weeks diary. Pressure pain thresholds were assessed bilaterally over the temporalis muscle, C5-C6 joint, second metacarpal and tibialis anterior muscle to determine widespread pressure pain hyperalgesia. The Hospital Anxiety and Depression Scale assessed anxiety and depression. The State-Trait Anxiety Inventory evaluated the state and trait levels of anxiety. The Headache Disability Inventory evaluated the burden of headache. Health-related quality of life was determined with the SF-36 questionnaire. Groups were considered as positive (three or more criteria) or negative (less than three criteria) on a clinical prediction rule: headache duration <8.5 h/day; headache frequency <5.5 days/week; bodily pain <47 and vitality <47.5., Results: The ANCOVA revealed that subjects in group 1 (positive rule, n = 89) exhibited longer headache history, shorter headache duration, lower headache frequency, higher widespread pressure hyperalgesia, higher anxiety trait levels, and lower quality of life (all, P < 0.01) than those subjects within group 2 (negative rule, n = 108). Differences were similar between men and women., Conclusions: This study identified a subgroup of patients with TTH with higher sensitization, higher chronicity of headaches and worse quality of life but lower frequency and duration of headache episodes. This subgroup of individuals with TTH may need particular attention and specific therapeutic programs for avoiding potential chronification.

Background: Previous pilot studies suggest the presence of heterogeneous sensitivity to pressure in primary headaches without considering the frequency of headache episodes., Objective: To investigate the differences in topographical pressure pain sensitivity maps in the temporalis muscle between individuals with frequent episodic (FETTH) and chronic (CTTH) tension-type headache by controlling the presence of anxiety and depression., Methods: oPressure pain thresholds (PPTs) were assessed bilaterally from 9 points distributed over the temporalis muscle (3 points in the anterior portion, 3 in the middle portion, and the remaining 3 in the posterior portion of the muscle belly) in 113 patients with FETTH and 91 with CTTH in a blinded design. Topographical pressure pain sensitivity maps based on interpolation of the PPTs were constructed. Clinical features of headache were collected in a 4-week headache diary. Anxiety and depression (Hospital Anxiety and Depression Scale) were also assessed., Results: The multilevel analysis of covariance found significant difference in PPT levels between points (F = 47.649; P < 0.001), but not between groups (F = 0.801; P = 0.602) or sides (F = 0.331; P = 0.565). No significant effect of gender (F = 0.785; P = 0.667), depression (F = 0.515; P = 0.846), or anxiety (F = 0.639; P = 0.745) was observed. Post hoc comparisons revealed: (1) no differences between FETTH and CTTH; (2) no side-to-side differences; and (3) anterior-to-posterior gradient with the most sensitive points located in the anterior column, followed by those located in the central column and the posterior column of the muscle (all, P < 0.001)., Conclusions: This study confirmed an anterior-to-posterior gradient of sensitivity to pressure in both groups, with the highest sensitivity at the anterior part of the muscle. Further, we found similar pressure pain sensitivity in the trigeminal area in people with FETTH or CTTH with no association with depressive or anxiety levels., (© 2017 World Institute of Pain.)

Objective: To investigate widespread pressure hyperalgesia in the trigemino-cervical and extra-trigeminal (distant pain-free) regions in women with episodic and chronic migraine., Methods: Fifty-one women with episodic migraine, 52 women with chronic migraine, and 52 healthy women without headache history were recruited. Pressure pain thresholds (PPT) were bilaterally assessed over the trigeminal area (i.e., temporalis muscle), cervical area (i.e., C5/C6 zygapophyseal joint), and two extra-trigeminal areas (i.e., second metacarpal, tibialis anterior muscle) in a blinded design. Clinical features of migraine and anxiety/depression (Hospital Anxiety and Depression Scale, HADS) were also assessed., Results: The multivariate analysis of covariance (ANCOVA) revealed that PPTs were significantly decreased bilaterally over trigeminal and extra-trigeminal points in migraine patients compared to healthy women (all sites, P < 0.001). No differences between episodic and chronic migraine were observed (all, P > 0.919). The presence of neck pain (all, P > 0.282), anxiety (P > 0.425) or depression (all, P > 0.316) did not influence the results. The intensity of migraine pain was negatively associated with widespread pressure pain sensitivity: The greater the intensity of migraine attacks, the lower the widespread PPT levels, i.e., the greater the widespread sensitization., Conclusions: This study found similar widespread pressure hypersensitivity in women with episodic or chronic migraine suggesting that central manifestations are involved both in episodic and chronic migraine., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To investigate potential relationships of clinical (age, function, side of pain, years with pain), physical (cervical range of motion, pinch grip force), psychological (depression), and neurophysiological (pressure and thermal pain thresholds) outcomes and hand pain intensity in carpal tunnel syndrome (CTS)., Methods: Two hundred and forty-four (n=224) women with CTS were recruited. Demographic data, duration of the symptoms, function and severity of the disease, pain intensity, depression, cervical range of motion, pinch tip grip force, heat/cold pain thresholds (HPT/CPT), and pressure pain thresholds (PPT) were collected. Correlation and regression analysis were performed to determine the association among those variables and to determine the proportions of explained variance in hand pain intensity., Results: Significant negative correlations existed between the intensity of pain and PPTs over the radial nerve, C5/C6 zygapophyseal joint, carpal tunnel and tibialis anterior muscle, HPT over the carpal tunnel, cervical extension and lateral-flexion, and thumb-middle, fourth, and little finger pinch tip forces. Significant positive correlations between the intensity of hand pain with function and depression were also observed. Stepwise regression analyses revealed that function, thumb-middle finger pinch, thumb-little finger pinch, depression, PPT radial nerve, PPT carpal tunnel, and HPT carpal tunnel were significant predictors of intensity of hand pain (R²=0.364; R² adjusted=0.343; F=16.87; P<0.001)., Conclusion: This study showed that 36.5% of the variance of pain intensity was associated to clinical (function), neurophysiological (localized PPT and HPT), psychological (depression), and physical (finger pinch tip force) outcomes in women with chronic CTS.

Objectives: The objectives of this study are (1) to assess the presence of myofascial trigger points (TrPs) and widespread pressure hyperalgesia; and (2) to assess the relationship between the presence of active TrPs, pain intensity, and widespread pressure hypersensitivity in individuals with postmeniscectomy pain., Methods: Thirty-three patients with postmeniscectomy pain, 46 to 60 years of age, and 33 matched controls participated. TrPs were explored bilaterally within the tensor fasciae latae, rectus femoris, vastus lateralis, vastus medialis, adductor magnus, adductor longus, semitendinosus, biceps femoris, and gastrocnemius muscles in a blinded manner. TrPs were considered active if the referred pain reproduced knee symptoms. Pressure pain thresholds (PPT) were also assessed bilaterally over the vastus medialis, vastus lateralis, patellar tendon, second metacarpal, and tibialis anterior. Pain was collected with a numerical pain rate scale (0 to 10)., Results: Patients with postmeniscectomy pain showed a greater (P<0.001) number of active TrPs (mean: 2±1) and a similar number (P=0.611) of latent TrPs (mean: 4±4) than pain-free controls (mean latent TrP: 4±1). A greater number of active TrPs was associated with higher pain intensity (r=0.352; P=0.045). Patients also exhibited reduced PPT over the affected vastus medialis and patellar tendon (P<0.05) and bilaterally over the tibialis anterior muscle (P=0.001). A greater the number of active muscle TrPs was also associated with widespread pressure pain hyperalgesia., Conclusions: The referred pain elicited by active TrPs reproduced knee symptoms in patients with postmeniscectomy pain. Patients also showed localized reduction of PPT. The number of TrPs was associated with the intensity of pain and pressure hyperalgesia. Our findings suggest the presence of peripheral sensitization in patients with postmeniscectomy pain could be associated with the presence of active TrPs.

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: The purpose of this study was to determine the effects of deep dry needling (DDN) on spasticity, pressure sensitivity, and plantar pressure in patients who have had stroke., Methods: A randomized controlled trial was conducted. Thirty-four patients who previously had a stroke were randomly assigned either an experimental group that received a single session of DDN over the gastrocnemius and tibialis anterior muscles on the spastic leg or a control group that received no intervention. Spasticity (evaluated with the Ashworth Scale); pressure pain thresholds over the deltoid muscle, second metacarpal, and tibialis anterior muscle; and plantar pressure (baropodometry) were collected by a blinded assessor before and 10 minutes after intervention., Results: A greater number of individuals receiving DDN exhibited decreased spasticity after the intervention (P < .001). The analysis of covariance showed that pressure pain thresholds increased bilaterally in patients receiving DDN compared with those who did not receive the intervention (P < .001). The analysis of covariance also found that patients receiving DDN experienced bilateral increases of support surface in the forefoot, unilateral increase of the support surface in the rear foot of the treated (affected) side, and bilateral decreases in mean pressure (all, P < .02) as compared with those who did not receive DDN., Conclusions: Our results suggest that a single session of DDN decreases spasticity and widespread pressure sensitivity in individuals with poststroke spasticity. Deep dry needling also induced changes in plantar pressure by increasing the support surface and decreasing the mean pressure., (Copyright © 2014 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.)

Study Design: Prospective, randomized, controlled single-blind intervention trial., Objectives: Shock-absorbing insoles (SAIs), compared with usual insoles, were hypothesized to result in larger increases in pressure pain threshold (PPT) after 3 weeks of use., Background: Shock-absorbing insoles can decrease self-reported pain among young soccer players training on artificial turf. However, nothing is known about the underlying changes in pain sensitivity assessed by PPT. Methods Seventy-five players were included from the youth teams of under 15, under 17, and under 19 years of age, playing for the Aalborg Boldspilklub (AaB) professional sports club. After a randomization stratified by team and age, players were divided into 2 groups, one that received SAIs and a control group that used their usual insoles. Assessments were made in both groups after 3 weeks of training on artificial turf (baseline) and 3 weeks later (follow-up). The primary outcome was change in PPTs from baseline to follow-up, with PPTs measured over 13 locations on the plantar surface of the foot, leg, and low back of the nonpreferred kicking leg., Results: A significantly larger increase was found in PPTs from baseline to follow-up for the SAI group compared with the control group (mean difference, 62 kPa; 95% confidence interval [CI]: 40, 85 kPa). The PPTs increased significantly more among the SAI group compared with the control group (P<.05) for the abductor digiti minimi (mean difference, 82 kPa; 95% CI: 6, 157 kPa), tibialis anterior (mean difference, 125 kPa; 95% CI: 20, 230 kPa), medial gastrocnemius (mean difference, 83 kPa; 95% CI: -6, 171 kPa), and erector spinae (mean difference, 86 kPa; 95% CI: -17, 188 kPa)., Conclusion: The use of SAIs resulted in increased PPTs after 3 weeks of training on artificial turf compared with controls, suggesting a protective role of SAIs in pressure sensitivity and pain perception.

Study Design: Randomized clinical trial., Objectives: To determine the effects of trigger point dry needling (TrPDN) on neck pain, widespread pressure pain sensitivity, and cervical range of motion in patients with acute mechanical neck pain and active trigger points in the upper trapezius muscle., Background: TrPDN seems to be effective for decreasing pain in individuals with upper-quadrant pain syndromes. Potential effects of TrPDN for decreasing pain and sensitization in individuals with acute mechanical neck pain are needed. Methods Seventeen patients (53% female) were randomly assigned to 1 of 2 groups: a single session of TrPDN or no intervention (waiting list). Pressure pain thresholds over the C5-6 zygapophyseal joint, second metacarpal, and tibialis anterior muscle; neck pain intensity; and cervical spine range-of-motion data were collected at baseline (pretreatment) and 10 minutes and 1 week after the intervention by an assessor blinded to the treatment allocation of the patient. Mixed-model analyses of variance were used to examine the effects of treatment on each outcome variable., Results: Patients treated with 1 session of TrPDN experienced greater decreases in neck pain, greater increases in pressure pain threshold, and higher increases in cervical range of motion than those who did not receive an intervention at both 10 minutes and 1 week after the intervention (P<.01 for all comparisons). Between-group effect sizes were medium to large immediately after the TrPDN session (standardized mean score differences greater than 0.56) and large at the 1-week follow-up (standardized mean score differences greater than 1.34)., Conclusion: The results of the current randomized clinical trial suggest that a single session of TrPDN may decrease neck pain intensity and widespread pressure pain sensitivity, and also increase active cervical range of motion, in patients with acute mechanical neck pain. Changes in pain, pressure pain threshold, and cervical range of motion surpassed their respective minimal detectable change values, supporting clinically relevant treatment effects. Level of Evidence Therapy, level 1b-.

Background: The genetic influence of Val158Met polymorphisms, one of the potential genetic determinants for nociceptive processing, has not been previously investigated in women with carpal tunnel syndrome (CTS)., Objectives: To investigate the association between the Val158Met polymorphism with CTS and to assess the relationship between the Val158Met polymorphism and the clinical outcomes and widespread pressure pain hypersensitivity in women with CTS., Study Design: Case control study., Setting: Neurology department at an urban hospital., Method: One hundred nine (n = 109) women (mean age: 47 ± 9 years) with a clinical and electrodiagnostic diagnosis of CTS and 109 matched healthy women participated. After amplifying the Val158Met polymorphism by polymerase chain reactions, rs4680 genotype frequencies and allele distributions were calculated. We classified individuals according to their Val158Met polymorphism: Val/Val, Val/Met, Met/Met. The intensity of the pain was assessed with a numeric rating scale (0-10) and disability was determined with the Boston Carpal Tunnel Questionnaire. Pressure pain thresholds were bilaterally assessed over median, radial, and ulnar nerve trunks; C5-C6 facet joints; and carpal tunnel and tibialis anterior muscles.Institutional Review Board: The study project was approved by the local human research committee (HUFA-12/14). All participants signed an informed consent prior to their inclusion in the study., Results: The distribution of the 3 Val158Met genotypes (Val/Val, Val/Met, Met/Met) and alleles was not significantly different between women with CTS and healthy women (Chi-Square = 0.498; P = 0.780). Women with CTS carrying the Met/Met genotype showed higher levels of pain and disability than those with the Val/Met genotype (P < 0.01) and with the Val/Val genotype (P < 0.001). No differences in the years with pain (P = 0.954), age (P = 0.740), depression (P = 0.530), severity of CTS (P = 0.744) or presence of unilateral-bilateral symptoms (P = 0.279) existed depending on the rs4680 Val158Met genotype. No significant differences in widespread pressure pain sensitivity were observed in any of the points depending on the rs4680 Val158Met genotype (P > 0.315)., Limitations: We only recruited women from a specialized department., Conclusion: Current results indicated that the Val158Met polymorphism seems not to be a risk factor for the development of CTS; however, it was associated with increased perception of pain and higher disability scores.

Objectives: To determine the differences in pain, disability, depression, and pressure sensitivity between men and women with fibromyalgia syndrome (FMS), and to analyze the relationship between pain and pressure sensitivity in FMS., Design: A cross-sectional study., Setting: Gender differences in pain sensitivity in individuals with FMS have not been yet clarified., Patients: Twenty-four men (age: 52 ± 6 years) and 24 age-matched women (age: 52 ± 5 years) with FMS diagnosed according to 1990 American College of Rheumatology criteria participated., Outcome Measures: Pressure pain thresholds (PPTs) over the 18 tender points and over the second metacarpal and tibialis anterior muscle were assessed. The intensity and duration of pain, tender point count, the Fibromyalgia Impact Questionnaire, and depression (Beck Depression Inventory-II) were calculated., Results: Women reported higher intensity of pain, tender point count, and depression than men (P < 0.01). Men reported a longer history of pain and disability than women (P = 0.005). Women showed bilateral lower PPT over suboccipital, cervical spine, second rib, supraspinatus, lateral epicondyle, gluteal region, and second metacarpal than men (P < 0.05). Negative associations between tender point count and PPT were found in men and women. In men, negative correlations between the intensity of ongoing pain and PPT over the cervical spine were found. No significant association between PPT and other clinical outcome was seen., Conclusions: Women with FMS showed higher pain severity and lower PPT than men, whereas men exhibited longer duration of symptoms and disability. In men with FMS, the intensity of ongoing pain was positively correlated to pressure hyperalgesia over the neck. This study suggests that FMS could show a different phenotype in women and men and confirm that women exhibit lower PPT than men., (Wiley Periodicals, Inc.)

Study results evaluating pain thresholds in patients with Parkinson's disease (PD) vary widely. Thus, we designed our study to determine the effects of levodopa on the thresholds of pressure (PPT), heat (HPT) and cold pain (CPT) in PD patients with motor fluctuations (18 patients: 10 men, 8 women; age: 65 ± 10 years; mean disease duration: 11.6 ± 6 years), six of whom (33%) reported pain related to their disease. We compared these thresholds in patients in the ON and OFF states with those in 18 age- and sex-matched controls. Pain thresholds were assessed over: the frontal bones, C5-C6 zygapophyseal joints and second metacarpals (PPT); the dorsal aspect of the hand (HPT and CPT); and the tibialis anterior (TA) muscles. PD patients in the OFF state had lower PPT thresholds at all sites (P < 0.001) than healthy controls. Moreover, HPT and CPT thresholds were lower at all sites except over the TA muscle (P < 0.01). In the ON state, the PPT and CPT thresholds in PD patients were lower than in controls at all points, except over the TA (CPT) and the second metacarpals (PPT) P < 0.01. Pain thresholds were no different in PD patients in the ON or OFF state (P > 0.10), and the existence of pain did not influence the results. We detected mechanical and thermal pain hypersensitivity in PD patients in the OFF state, and levodopa administration did not increase these thresholds. Thus, while dopamine may modulate pain responses, other mechanisms are likely to be implicated in the modulation of these pain responses in PD patients., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Study Design: Cross sectional cohort study., Objective: To analyze the differences in the prevalence of trigger points (TrPs) between patients with acute whiplash-associated disorders (WADs) and healthy controls, and to determine if widespread pressure hypersensitivity and reduced cervical range of motion are related to the presence of TrPs in patients with acute WADs., Background: The relationship between active TrPs and central sensitization is not well understood in patients with acute WADs., Methods: Twenty individuals with a high level of disability related to acute WAD and 20 age- and sex-matched controls participated in the study. TrPs in the temporalis, masseter, upper trapezius, levator scapulae, sternocleidomastoid, suboccipital, and scalene muscles were examined. TrPs are defined as hypersensitive spots in a palpable taut band, producing a local twitch response and referred pain when palpated. Pressure pain threshold (PPT) was assessed bilaterally over the C5-6 zygapophyseal joints, second metacarpal, and tibialis anterior muscle. Active cervical range of motion, neck pain, and self-rated disability using the Neck Disability Index were also assessed., Results: The mean ± SD number of TrPs for the patients with acute WAD was 7.3 ± 2.8 (3.4 ± 2.7 were latent TrPs; 3.9 ± 2.5 were active TrPs). In comparison, healthy controls had 1.7 ± 2.2 latent and no active TrPs (P<0.01). In patients with acute WAD, the most prevalent sites for active TrPs were the levator scapulae and upper trapezius muscles. The number of active TrPs increased with higher neck pain intensity (P<0.001) and a higher number of days since the accident (P=.003). Patients had significantly lower PPTs in all tested locations and less active cervical range of motion than controls (P<.001). In the patient group, there were significant negative correlations between the number of active TrPs and PPT over the C5-C6 joints and cervical range of motion in flexion, extension, and rotation in both directions: the greater the number of active TrPs, the lower the bilateral PPT over the neck and the greater the cervical range of motion limitation., Conclusions: The local and referred pain elicited from active TrPs reproduced neck and shoulder pain patterns in individuals with acute WADs with higher levels of disability. Patients with acute WADs exhibited widespread pressure hypersensitivity and reduced cervical mobility. The number of active TrPs was related to higher neck pain intensity, the number of days since the accident, higher pressure pain hypersensitivity over the cervical spine, and reduced active cervical range of motion.

Objective: The purpose of this prospective case series was to examine the combined effects of soft tissue mobilization and nerve slider neurodynamic technique on pain and pressure sensitivity in women with chronic carpal tunnel syndrome (CTS)., Methods: Eighteen women with a clinical and electromyographic diagnosis of CTS participated. Patients completed the numerical pain rating scale (NPRS) for current, worst, and lowest pain intensity and underwent pain pressure threshold (PPT) testing over the median, radial, and ulnar nerves; the C5-C6 zygapophyseal joint; the carpal tunnel; and the tibialis anterior muscle. Pain was assessed at baseline and 1-week follow-up, whereas PPT were assessed at baseline and immediately after and 1-week after intervention. Each received soft tissue mobilization and nerve slider neurodynamic technique directed at different anatomical sites of potential entrapment of the median nerve., Results: A decrease in the mean current intensity and worst level of hand pain (P<.01) was found 1 week after the treatment session (mean changes, 2.2±1.1 points). A treatment effect for PPT levels over the C5-C6 zygapophyseal joint (P<.001) was found: PPT increased bilaterally 1 week after the intervention. No other significant changes in PPT levels were found (P>.195)., Conclusions: The application of soft tissue mobilization and neurodynamic technique decreased the intensity of pain but did not change pressure pain sensitivity in this group of women with chronic CTS., (Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

The aim of this study was to evaluate the changes in pressure pain sensitivity maps in untrained subjects over 2 subsequent sessions of eccentric exercise (ECC) expected to result in (a) delayed onset muscle soreness (DOMS) and (b) adaptation/recovery, respectively. Eleven healthy male subjects participated in this study. Pressure pain threshold (PPT), rate of perceived exertion (RPE), pain intensity, soreness area drawing, maximal voluntary contraction (MVC), and shoulder range of motion were assessed in session 1 before, immediately after, and 24 hours after ECC. The ECC protocol that was used to induce DOMS consisted of 50 eccentric contractions of the right shoulder that were divided into 5 bouts, including 10 contractions at MVC level separated by a 2-minute resting period. Session 2 was identical to session 1 and performed exactly 1 week later. There was only a significant increase in the RPE assessed before the exercise and 24 hours after the exercise in session 1 (p = 0.001). The average PPT only decreased significantly from before the exercise (660.2 ± 76.2 kPa) to 24 hours after the exercise (435.6 ± 59.3 kPa) in session 1 (p = 0.016). The present study confirmed a heterogeneous distribution of mechanical sensitivity before and after sessions of ECC. The first session of ECC underlined increased mechanical sensitivity because of DOMS, whereas the second session reflected an adaptation process. Our results support the potential role of ECC bouts in training regimens.

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.

Unlabelled: Our aim was to quantify spatial differences in pressure and thermal pain sensitivity maps between patients with unilateral lateral epicondylalgia (LE) and age- and sex-matched controls. Pressure (PPT), cold (CPT), and heat (HPT) pain thresholds were assessed over 12 points forming a 3 × 4 matrix (4 points in the superior part, 4 points in the middle, and 4 points in the lower part around the lateral epicondyle) bilaterally in 16 subjects with strictly unilateral LE and 16 age- and sex-matched controls in a blinded design. Topographical pain sensitivity maps to pressure and thermal stimulation over the elbow in patients with LE and healthy controls were calculated. A multilevel 3-way ANCOVA test was applied to detect differences in topographical maps between groups. Subjects with LE showed bilateral lower PPT, higher CPT (pain at higher temperature) and lower HPT (pain at lower temperature) at all the measurement points as compared to controls (all, P < .01). PPT were lower at points over the extensor carpi radialis brevis (ECRB) muscle as compared to points over the extensor digitorum communis muscle (P < .01) and over the extensor carpi ulnaris muscle (P < .001). CPT and HPT were not significantly different between points (P > .05). Topographical pressure and thermal pain sensitivity maps revealed bilateral hyperalgesia in patients with strictly unilateral LE. LE patients exhibited heterogeneously distributed pressure pain hyperalgesia while cold or heat maps were homogenous. The most sensitive localizations for PPT assessment corresponded to the muscle belly of the ECRB. Our results confirm the role of ECRB muscle in LE and argue for evidence of peripheral and central sensitization mechanisms in patients with strictly unilateral symptoms., Perspective: Topographical pressure and thermal sensitivity maps revealed bilateral hyperalgesia in patients with strictly unilateral lateral epicondylalgia (LE). LE patients exhibited heterogeneously distributed pressure pain hyperalgesia while cold or heat pain maps were homogenous. The most sensitive localizations for PPT assessment corresponded to the muscle belly of the ECRB., (Copyright © 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.)

The aim of the current study was to identify whether hyperexcitability of the central nervous system is a prognostic factor for individuals with carpal tunnel syndrome (CTS) likely to experience rapid and clinical self-reported improvement following a physical therapy program including soft tissue mobilization and nerve slider neurodynamic interventions. Women presenting with clinical and electrophysiological findings of CTS were involved in a prospective single-arm trial. Participants underwent a standardized examination and then a physical therapy session. The physical therapy sessions included both soft tissue mobilization directed at the anatomical sites of potential median nerve entrapment and a passive nerve slider neurodynamic technique targeted to the median nerve. Pressure pain thresholds (PPT) over the median, radial and ulnar nerves, C5-C6 zygapophyseal joint, carpal tunnel and tibialis anterior muscle were assessed bilaterally. Additionally, thermal detection and pain thresholds were measured over the carpal tunnel and thenar eminence bilaterally to evaluate central nervous system excitability. Subjects were classified as responders (having achieved a successful outcome) or non-responders based on self-perceived recovery. Variables were entered into a stepwise logistic regression model to determine the most accurate variables for determining prognosis. Data from 72 women were included in the analysis, of which 35 experienced a successful outcome (48.6%). Three variables including PPT over the C5-C6 joint affected side <137 kPa, HPT carpal tunnel affected side <39.6º and general health >66 points were identified. If 2 out of 3 variables were present (LR + 14.8), the likelihood of success increased from 48.6 to 93.3%. We identified 3 factors that may be associated with a rapid clinical response to both soft tissue mobilization and nerve slider neurodynamic techniques targeted to the median nerve in women presenting with CTS. Our results support that widespread central sensitization may not be present in women with CTS who are likely to achieve a successful outcome with physical therapy. Future studies are now necessary to validate these findings.

Introduction: The aim was to investigate bilateral, wide-spread pressure pain hyperalgesia in symptomatic (trigeminocervical) and non-symptomatic (pain-free distant) regions in children with frequent episodic tension-type headache (FETTH)., Methods: Twenty-five children, 6 boys and 19 girls (mean age, 8.9 +/- 1.8 years) with FETTH and 50 age- and sex-matched healthy children (12 boys, 38 girls; mean age: 8.8 +/- 1.7 years) were recruited. Pressure pain thresholds (PPTs) were bilaterally assessed over temporalis muscle, upper trapezius muscle, second metacarpal and tibialis anterior muscles in a blinded design., Results: The results showed that PPT levels were significantly decreased bilaterally over the temporalis, upper trapezius and tibialis muscles, and the second metacarpal in children with FETTH as compared to controls (all sites, P < 0.001). No significant differences in the magnitude of PPT decrease between the upper trapezius muscle, second metacarpal and tibialis anterior muscles were found. PPT over both upper trapezius muscles were negatively correlated with the history and intensity of headache (r(s) = -0.415; P = 0.045)., Conclusions: The findings revealed bilateral, wide-spread pressure pain hypersensitivity in children with FETTH suggesting that wide-spread central sensitisation is involved in children with this headache pain condition.

Objective: To assess topographical pressure pain sensitivity maps of the hand in patients with unilateral carpal tunnel syndrome (CTS) as compared with healthy subjects., Methods: A total of 20 women with CTS (ages 32-52 years) and 20 healthy matched women (ages 32-51 years) were recruited. Pressure pain thresholds (PPTs) were measured bilaterally over 30 locations of the palm of each hand by an assessor blinded to the subjects' conditions., Results: Patients showed lower PPTs in both hands in all of the measurement points as compared with controls (P < 0.001 for all). PPTs were lower in those points over the proximal phalanx of the fingers and the thenar eminency as compared with those points located over the distal phalanx of the fingers (P < 0.001). CTS patients showed lower PPT levels in dermatomes C6, C7, and C8 when compared with healthy controls (P < 0.001 for all), but without differences between dermatomes (P = 0.4). PPT was negatively correlated with both hand pain intensity and duration of symptoms (P < 0.001 for all)., Conclusion: Our findings revealed bilateral generalized pressure pain hyperalgesia in unilateral CTS because lower PPT levels were found in all of the points. The pressure pain hyperalgesia was not uniformly distributed since PPTs were lower in points over the proximal phalanx of the fingers and the thenar eminency as compared with those points located over the distal phalanx of the fingers. The decrease in PPT levels was associated with the intensity and the duration of the pain symptoms, supporting a role of both peripheral and central sensitization mechanisms in this pain condition.

Objectives: The objective of this study was to analyze the presence of generalized pressure pain hypersensitivity over nerve tissues in trigeminal and nontrigeminal regions in children with frequent episodic tension-type headache (FETTH)., Methods: Thirty children, 7 boys and 23 girls (mean age: 8.8 +/- 1.7 years) with FETTH and 50 age- and gender-matched healthy children (14 boys, 36 girls; mean age: 8.5 +/- 2.1 years; P = .743) were recruited. Pressure pain thresholds (PPTs) were bilaterally assessed over supra-orbital (V1), infra-orbital (V2), mental (V3), median (C5), radial (C6), and ulnar (C7) nerves by an assessor who was blinded to the patient's condition., Results: The analysis of variance showed that PPT levels were significantly bilaterally decreased over both trigeminal (supra-orbital, infra-orbital, and mental) and nontrigeminal (median, ulnar, and radial) nerves in children with FETTH as compared with control subjects (all sites, P < .001). There was a greater magnitude of PPT decrease within trigeminal nerves as compared with nontrigeminal nerves (P < .03). PPTs over infra-orbital (r(s) = -0.4, P < .05) and radial (r(s) = -0.5, P < .01) nerves were negatively correlated with the duration of headache attacks (P < .05)., Conclusions: Our study revealed bilateral and generalized pressure hypersensitivity over both trigeminal and nontrigeminal nerves in children with FETTH. Diffuse hypersensitivity of peripheral nerves evidences the presence of hyperexcitability of the central nervous system in children with FETTH.

Purpose: The aim of this study was to apply topographical techniques to investigate changes in pressure pain sensitivity after induction of delayed onset muscle soreness (DOMS) in the elbow region in healthy subjects., Methods: Pressure pain thresholds (PPT) were assessed over 12 points forming a 3 x 4 matrix (4 points in the superior part, 4 points in the middle, and 4 points in the lower part around the lateral epicondyle) over the dominant elbow in 13 healthy men, and pressure sensitivity maps were calculated. DOMS, as a model for lateral epicondylalgia (LE), was induced by repetitive high-level eccentric contractions of the wrist extensor muscles. PPT maps were assessed before, immediately after, and 24 h after eccentric exercise (DOMS)., Results: The two-way repeated-measure ANOVA detected significant differences in mean PPT for the measurement points (F = 5.96, P < 0.001), with lower PPT over the points located over the extensor carpi radialis brevis muscle. There was also a significant effect of time (F = 121.3, P < 0.001) but no time x point location interaction (F = 0.7, P = 0.8). PPT were lower 24 h after (P < 0.001) but not immediately after (P > 0.05) eccentric exercise., Conclusions: The study provides new key information regarding mechanical pain hyperalgesia in experimentally induced LE. Topographical pressure pain sensitivity maps from the elbow region revealed heterogeneously distributed mechanical sensitivity before and during DOMS. The most sensitive localizations for PPT assessment correspond to the muscle belly of the extensor carpi radialis brevis. Our results support the implication of the extensor carpi radialis brevis muscle in LE.

Objective: This study analyzed the immediate effect of hamstring muscle stretching on pressure pain sensitivity over the masseter and the upper trapezius muscles and maximum active mouth opening in healthy subjects., Methods: One hundred twenty volunteers, 70 males and 50 females, between the ages of 22 and 47, were randomly divided into 3 groups: group 1 (control group) that did not receive any intervention, group 2 where a unilateral hamstring muscle stretching was applied, and group 3 where a bilateral stretching was applied. Pressure pain thresholds (PPTs) were bilaterally assessed over the masseter and upper trapezius muscles pre- and 5 minutes posttreatment by an assessor blinded to group assignment. Maximum mouth opening was also assessed pre- and 5 minutes posttreatment. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the intervention. The primary analysis was the group x time interaction., Results: The ANOVA revealed significant group x time interaction for changes in PPTs over the upper trapezius (F = 4.5; P = .01) and masseter (F = 6.3; P = .002) muscles. Pre-post effect sizes were moderate (0.5 >d > 0.7) for both stretching groups and negative (d < -0.2) for the control group. A significant group x time interaction (F = 8.15; P < .001) for maximum mouth opening was also found; both experimental groups showed greater improvement when compared to the control group (P < .001). Pre-post effect sizes were large (d > 0.7) for both stretching groups and negative (d < -0.2) for the control group., Conclusions: The application of a stretching of the hamstring musculature produced an immediate increase in PPTs over both masseter and upper trapezius muscles in healthy subjects., (Copyright 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

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: The purpose of this study was to investigate the immediate effects of head-neck massage on heart rate variability (HRV), mood states, and pressure pain thresholds (PPTs) in patients with chronic tension-type headache (CTTH)., Methods: Eleven patients (8 females), between 20 and 68 years old, with CTTH participated in this crossover study. Patients received either the experimental treatment (massage protocol) or a placebo intervention (detuned ultrasound). Holter electrocardiogram recordings (standard deviation of the normal-to-normal interval, square root of mean squared differences of successive NN intervals, index HRV, low-frequency component, and high-frequency component), PPT over both temporalis muscles, and Profile of Mood States questionnaire (tension-anxiety, depression-dejection, anger-hostility, vigor, fatigue, confusion) were obtained preintervention, immediately after intervention, and 24 hours postintervention. Self-reported head pain was also collected preintervention and 24 hours postintervention. Separate analyses of covariance (ANCOVAs) were performed with each dependent variable. The hypothesis of interest was group x time interaction., Results: The ANCOVA showed a significant group x time interaction for index HRV (F = 4.5, P = .04), but not for standard deviation of the normal-to-normal interval (F = 1.1, P = .3), square root of mean squared differences of successive NN intervals (F = 0.9, P = .3), low-frequency component (F = 0.03, P = .8), or high-frequency component (F = 0.4, P = .5) domains. Pairwise comparisons found that after the manual therapy intervention, patients showed an increase in the index HRV (P = .01) domain, whereas no changes were found after the placebo intervention (P = .7). The ANCOVA also found a significant group x time interaction for tension-anxiety (F = 5.3, P = .03) and anger-hostility (F = 4.6, P = .04) subscales. Pairwise comparisons found that after the manual therapy intervention, patients showed a decrease in tension-anxiety (P = .002) and anger-hostility (P = .04) subscales, whereas no changes were found after the placebo intervention (P > .5 both subscales). No significant changes were found in PPT levels (right F = 0.3, P = .6, left F = 0.4, P = .5). A significant group x time interaction for pain (F = 4.8, P = .04) was identified. No influence of sex was found (F = 1.5, P = .3). Pairwise comparisons showed that head pain (numerical pain rating scale) decreased 24 hours after manual therapy (P < .05) but not after the placebo intervention (P = .9)., Conclusions: The application of a single session of manual therapy program produces an immediate increase of index HRV and a decrease in tension, anger status, and perceived pain in patients with CTTH.

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: The purpose of this study was to investigate if the application of a cervical myofascial induction technique targeted to the ligamentum nuchae resulted in changes in cervical range of motion and pressure pain thresholds (PPT) in asymptomatic subjects., Methods: Thirty-five subjects, 8 men and 27 women (mean age, 21 +/- 4 years), without a current history of neck, shoulder, or arm pain participated. Participants were randomly divided into 2 groups: the experimental group, which received a real cervical myofascial induction technique, and the control group, which received a sham-manual procedure. Bilateral PPT levels over C5-C6 zygapophyseal joints and tibialis anterior muscles and neck mobility were assessed preintervention and 5 minutes postintervention by an assessor blinded to the treatment allocation of the subject. Separate mixed-model analyses of variance were used to examined the effects of the treatment on neck mobility and PPT levels as the dependent variable, with group (experimental or control) as the between-subjects variable and time (pre-post test) or side (dominant, nondominant) as the within-subjects variable. The hypothesis of interest was the group x time interaction at an a priori alpha level equal to .05., Results: The group x time interaction was statistically significant for cervical flexion (F = 5.4; P = .03), extension (F = 3.3; P = .045), and left lateral-flexion (F = 4.6; P = .04), but not for right lateral-flexion (F = 2.5; P = .1), right rotation (F = 0.5; P = .5), and left rotation (F = 0.09; P = .2). Subjects receiving the real cervical myofascial induction technique experienced greater improvement in cervical mobility when compared with the control group. The group x time interaction did not reveal any significance for PPT in the C5-C6 zygapophyseal joints (F = 0.5; P = .5) and in the tibialis anterior muscle (F = 0.2; P = .8)., Conclusions: The application of a cervical myofascial induction technique resulted in an increase in cervical flexion, extension, and left lateral-flexion, but not rotation motion in a cohort of healthy subjects. No changes in PPT in either C5-C6 zygapophyseal joint (local point) or tibialis anterior muscle (distant point) were found.

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.

Objectives: To screen for the presence of latent and active myofascial trigger points (MTrPs) in patients with unilateral shoulder and arm pain and perform topographical mapping of mechanical pain sensitivity bilaterally in the infraspinatus muscles., Methods: Nineteen patients with unilateral musculoskeletal shoulder pain participated in the study. The area overlying the infraspinatus on each side was divided into 10 adjacent sub-areas of 1cm(2), corresponding to the area of a pressure algometer probe. Pressure pain threshold (PPT) was measured in each sub-area bilaterally in the infraspinatus muscles. Following PPT measurement, an acupuncture needle was inserted into each sub-area five times in different directions in order to induce local twitch response and/or referred pain., Results: A significantly lower PPT level in the infraspinatus muscle was detected on the painful side compared with the non-painful side (P=0.001). PPT at midfiber region of the infraspinatus muscles was lower than that at other muscle parts (P<0.05). Multiple, but not single, active MTrPs were found in the infraspinatus muscle on the painful side and there were also multiple latent MTrPs bilaterally in the infraspinatus muscles. PPT at active MTrPs was much lower than the latent MTrPs and again lower than the non-MTrPs., Conclusions: There exists bilateral mechanical hyperalgesia in patients with unilateral shoulder pain. Further, the association of multiple active MTrPs with unilateral shoulder pain and the heterogeneity of mechanical pain sensitivity distribution suggest a crucial role of peripheral sensitization in chronic myofascial pain conditions. Additionally, the locations of MTrPs identified with dry needling correspond well to PPT topographical mapping, suggesting that dry needling and PPT topographical mapping are sensitive techniques in the identification of MTrPs.

Objective: This study examines if C7-T1 manipulation results in changes in pressure pain thresholds (PPT) over bilateral C5-C6 zygapophyseal joints in asymptomatic subjects., Methods: Thirty subjects, 13 men and 17 women, without a current history of neck, shoulder, or upper extremity pain participated. Participants were randomly divided into 3 groups: experimental dominant group, subjects who received the manipulative thrust directed at the right side of the C7-T1 joint; experimental nondominant group, those who received the thrust on the left side of the C7-T1 joint; and a placebo group, those who received a sham-manual procedure. The outcome measure was the PPT on both right and left C5-C5 zygapophyseal joints, which was assessed at preintervention and 5 minutes postintervention by an assessor blinded to the treatment allocation of the subject. A 3-way repeated measures analysis of covariance was used to evaluate changes in PPT., Results: The analysis of covariance revealed time x group (F = 32.3; P < .001), time x side (F = 4.9; P < .05), time x sex (F = 7.93; P < .01), and time x group x sex (F = 7.606; P < .001) interactions. Post hoc analyses found that (a) both experimental groups showed greater improvements in PPT than the placebo group (P < .05), without significant differences between them (P > .6); (b) the right side had greater increases in PPT in both experimental groups (P < .05), but not within the placebo group (P > .8); (c) men experienced greater increases in PPT levels than women, particularly in the experimental nondominant group (P < .01). Within-group effect sizes were large for both experimental groups (d > 1), but small for the placebo condition (d < 0.2)., Conclusions: These results suggest that a C7-T1 manipulation induced changes in PPT in both right and left C5-C6 zygapophyseal joints in healthy subjects.

Objective: This study aimed to establish whether increased sensitivity to mechanical stimuli is present in neural tissues in chronic tension-type headache (CTTH)., Background: Muscle hyperalgesia is a common finding in CTTH. No previous studies have investigated the sensitivity of peripheral nerves in patients with CTTH., Design: A blinded controlled study., Methods: Pressure pain thresholds (PPT) and pain intensity following palpation of the supra-orbital nerve (V1) were compared between 20 patients with CTTH and 20 healthy matched subjects. A pressure algometer and numerical pain rate scale were used to quantify PPT and pain to palpation. A headache diary was kept for 4 weeks to substantiate the diagnosis and record the pain history., Results: The analysis of variance demonstrated significantly lower PPT for patients (0.86+/-0.13 kg/cm2) than controls (1.50+/-0.19 kg/cm2) (P<.001). Pain to palpation was also higher for patients (2.73+/-1.58) than controls (0.15+/-0.28) (P<.001). Within the CTTH group, intensity, frequency, and duration of the headaches were negatively correlated with PPT (rsor=0.72; P<.001)., Conclusions: These findings reveal that mechanical hypersensitivity is not limited to muscles but also occurs in cranial nerves, and that the level of sensitization, either due to peripheral or central processes, is related to the severity of the primary headache.

Design: A placebo, control, repeated-measures, single-blinded randomized study., Objectives: To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to, the intervention., Background: Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions., Methods: Fifteen asymptomatic volunteers (7 male, 8 female; aged 19-25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days, at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate, was used to evaluate changes in PPT., Results: The analysis of variance detected a significant effect for intervention (F = 31.46, P < .001) and for time (F = 33.81, P < .001), but not for side (F = 0.303, P > .5). A significant interaction between intervention and time (F = 15.74, P < .001) was also found. Gender did not influence the comparative analysis (F = 0.252, P > .6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P < .001). No significant changes in PPT levels were found after the placebo and control interventions (P > .6). Within-group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d > 1.0), but small after placebo or control intervention (d < 0.1)., Conclusions: The application of a manipulative intervention directed at the posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

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.

Background: Nummular headache (NH) is a primary disorder presenting with localized pain that is circumscribed to a coin-shaped area of the head surface., Methods: In 12 patients with NH (3 men and 9 women, 21 to 67 years old), we measured the pressure pain threshold (PPT) in several points while they were headache-free. The following cephalic and extracephalic points were explored: the symptomatic cranial area, a symmetrical point on the nonsymptomatic side, and 3 standardized pairs of symmetrical points (anterior part of the temporal muscle, upper trapezius muscle, and distal dorsal part of the second finger). Three consecutive PPT readings were obtained with an algometer on each point, and the repeatability of these measurements was always high (ICC: 0.93 to 0.97)., Results: Mean PPT was lower in the symptomatic cranial area than in the contra-lateral symmetrical point (1.8 +/- 0.6 kg/cm(2) vs 2.4 +/- 0.6 kg/cm(2); P < .001), whereas in the remaining reference points PPT was almost equal on both sides., Conclusions: According to these data, NH seems to be associated with a local increase of pain sensitivity to mechanical stimulation.