2012 aaom shah neuromusculoskeletal pain lessons from the myofascia
TRANSCRIPT
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Neuromusculoskeletal Pain: Lessons from the Myofascia
Jay P. Shah, MDRehabilitation Medicine Department
National Institutes of Health
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Disclosures
•
Nothing to disclose
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NIH Clinical Research Center “Bench to Bedside -
Bedside to Bench”
LaboratoriesLaboratories
Inpatient Care
Outpatient Care
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Pattern-generating mechanism (Neuromatrix)
Brain areas encoding pain experience and behaviorsCultural,
past experience,personality
attention
Autonomic endocrine, immune variables
CNS Plasticity
Sensitization
Pathogenic inputs
Visceral inputs
Somatosensory inputs
Melzack, Trends Neurosci 1990; 13:88-92
Perception
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Adapted from Butler, DS The Sensitive Nervous System
Pain Mechanisms
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• Review the diagnostic criteria for myofascial pain and demonstrate the referral patterns of common myofascial trigger points (MTrPs)
• Examine the unique neurobiology of muscle pain
• Discuss the dynamic interplay of muscle nociceptors and endogenous biochemicals in the initiation, amplification and perpetuation of peripheral and central sensitization
• Demonstrate that an active myofascial trigger point (MTrP)
in the upper trapezius has elevated levels of inflammatory mediators, neuropeptides, and cytokines, etc. –
substances
known to be associated with persistent pain states, sensitization and inflammation
Goals of Discussion
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•
Introduce novel applications of ultrasound techniques to visualize MTrPs, measure their stiffness properties and local blood flow
•
Demonstrate that MTrPs in the upper trapezius are stiffer than surrounding tissue and that active MTrPs can be distinguished from latent MTrPs by their high-resistance blood flow
Goals of Discussion
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Myofascial Trigger Points
A Very Common, Complex and Overlooked Cause of Non-articular Musculoskeletal Pain
Hans-Werner Weisskircher www.trigger-point.com
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Essential Clinical Criteria for Myofascial Pain
•
Palpation of a taut band•
Exquisitely tender spot (a myofascial trigger point) in the taut band
•
Reproduction of the subject’s symptomatic painGerwin et al. Interrater reliability in myofascial trigger point examination. Pain. 1997;69(1-2):65-73
Hans-Werner Weisskircher www.trigger-point.com
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•
Palpation of a taut band•
Exquisitely tender spot (a myofascial trigger point) in the taut band
•
Reproduction of the subjects symptomatic painGerwin et al. Interrater reliability in myofascial trigger point
examination. Pain. 1997;69(1-2):65-73
Courtesy Marta Imamura
Essential Clinical Criteria for Myofascial Pain
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Myofascial Trigger Points
2-5 areas in hard, palpable bands of skeletal muscle:
Active –
cause a clinical pain complaint or other abnormal sensory symptoms
Latent –
show all the other characteristics of active MTrPs, except that they’re pain free
Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams & Wilkins; 1992.
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Upper Trapezius
Medial Pterygoid
Lateral PterygoidSCM (sternal division)
Masseter
Orofacial Pain 2º Myofascial Trigger
Points
Hans-Werner Weisskircher
www.trigger-point.com
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Release of Inflammatory mediators, Neuropeptides and Cytokines
Release of Inflammatory Release of Inflammatory mediators, Neuropeptides mediators, Neuropeptides and Cytokines and Cytokines
Courtesy Marta Imamura
Muscle Muscle InjuryInjury
Muscle Pain, Inflammation, and Sensitization
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Sensitize wide dynamic range neurons and higher centers leading to allodynia, hyperalgesia and…
Sensitize wide dynamic range Sensitize wide dynamic range neurons and higher centers neurons and higher centers leading to allodynia, hyperalgesia leading to allodynia, hyperalgesia andand……
Courtesy Marta Imamura
Muscle Muscle InjuryInjury
Muscle Pain, Inflammation, and Sensitization
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Courtesy Marta Imamura
… expansion of the receptive field of pain and referral of pain ……
expansion of the receptive expansion of the receptive
field of pain and referral of pain field of pain and referral of pain
Muscle Pain, Inflammation, and Sensitization
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Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger pointmanual. Baltimore: Williams & Wilkins; 1992.
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Common Referral Diagnoses for Pain Found to be of Myofascial Origin
•
Angina Pectoris (atypical)
•
Appendicitis
•
Atypical Migraine•
Tension Headache
•
Occipital Headache
•
Pectoralis Major
•
Lower Rectus Abdominis
•
Sternocleidomastoid, Temporalis, Mastic. Musc, Post. Cervicals,
Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams & Wilkins; 1992.
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“Since no specialty claims skeletal muscle as their organ, it
is often overlooked”David G. Simons, MD
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Muscle –
The “Orphan Organ”
•
NO specialty claims muscle as its organMuscle is ½ of the bodyNo organized emphasis on muscle pain (MTrP) research or student trainingClinicians focus primarily on treating the SYMPTOMS of myogenic pain, not the CAUSE of the pain (MTrPs)
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Active MTrPs can only be diagnosed by systematic palpation
Hans-Werner Weisskircher
www.trigger-point.com
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Apply Firm Pressure
Hans-Werner Weisskircher www.trigger-point.com
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Palpation, Palpation, Palpation•
Careful palpation of the surface of the body reveals distinct differences in the quality and density of the underlying tissue. Many of these areas or points will be tender:
•
A Shi points in Traditional Chinese Medicine
•
Kori in Japanese system•
Muskelharten in German system
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Nociceptor Function•
Encode Noxious Stimuli•
Possibly leading to pain
•
Maintain Tissue Health•
Initiate and maintain reaction to injury
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Nociceptors are Dynamic “Two-way”
Structures
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A Critical Efferent Nociceptor Function: Neuropeptide (Substance P, CGRP) Production
Courtesy Jan Dommerholt
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Muscle pain is NOT skin pain
Unique Neurobiology of Muscle Pain
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Muscle Pain is often Overlooked
“I’ll beBack!”
“Ohhh, my
Back!”
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Unique Characteristics of Muscle Pain
• Aching, cramping pain, difficult to localize and referred to deep and distant somatic tissues
• Muscle pain activates unique cortical structures Svensson P et al. Cerebral processing of acute skin and muscle pain in humans. J Neurophysiology July 1997; 78: 450-460.
• Inhibited more strongly by descending pain-modulating pathways XianMin Y, Mense S. Response Properties and descending control of rat dorsal horn neurons with deep receptive fields.
Neuroscience 1990; 39:823-831.
• Activation of muscle nociceptors is much more effective at inducing neuroplastic changes in dorsal horn neuronsWall PD, Woolf CJ.
J Physiol 1984 Nov;356:443-458.
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Distant Referral Patterns
Hans-Werner Weisskircher www.trigger-
point.com
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Powerful Descending Inhibition on Muscle Pain
Fields HL, Basbaum AI: Central nervous system mechanisms of pain modualtion. In Textbook of Pain; 1999:309-329.
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Afferent Bombardment of Muscle Nociceptors: 2nd
Messenger Cascades, Induction of Immediate Early
Genes and Protein Synthesis, Excitotoxicity and Cell Death
Activity Dependent PlasticityWall PD, Woolf CJ. Muscle but not cutaneous C-afferent input produces prolonged increases in the excitability of the flexion reflex in the rat. J Physiol. 1984 Nov;356:443-58.
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Muscle PainPeripheral Mechanisms
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BRADYKININRECEPTOR
BRADYKININRECEPTORBradykinin Receptor
Muscle Nociception
–
Binding of Substances to Matched Chemoreceptors
(B2→B1)
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Muscle PainSpinal Mechanisms
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• REDUCED SPATIAL RESOLUTION–
Due to lower density of muscle sensory afferents compared to the skin
• CONVERGENCE OF SENSORY INPUT–
Input from skin, bone, viscera, periosteum
Characteristics of Muscle Nociceptor Projections to Dorsal Horn
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• Sustained noxious stimulation (of Group IV fibers in muscle) leads to the opening of previously ineffective connections in dorsal horn neurons
• Intramuscular injection of various biochemicals (e.g., bradykinin, prostaglandins, serotonin, acidic saline, etc.) activates muscle nociceptors and causes allodynia and hyperalgesia
Dorsal Horn Changes in Pathologic Conditions –
Central Sensitization
DIVERGENCE OF SENSORY INPUT
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Expansion of Receptive Field by a Painful Muscle Stimulus
Hoheisel U, Mense S, Simons DG. Appearance of new receptive fields in rat dorsal horn neurons following noxious stimulation of skeletal muscle: a
model for referral of muscle pain? Neurosci lett 153:9-12, 1993
Selected neuron responds only to deep pressure in biceps femoris muscle
Biceps Femoris
Courtesy Jan Dommerholt
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Hoheisel U, Mense S, Simons DG.
Neurosci lett 153:9-12, 1993
5 min after BK injection in TA, the selected neuron can now be excited by additional RF’s located in deep
muscle that normally have high threshold
Expansion of Receptive Field by a Painful Muscle Stimulus
Courtesy Jan Dommerholt
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Hoheisel U, Mense S, Simons DG.
Neurosci lett 153:9-12, 1993
Expansion of Receptive Field by a Painful Muscle Stimulus
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Hoheisel U, Mense S, Simons DG.
Neurosci lett 153:9-12, 1993
Expansion of Receptive Field by a Painful Muscle Stimulus
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Hoheisel U, Mense S, Simons DG.
Neurosci lett 153:9-12, 1993
Expansion of Receptive Field by a Painful Muscle Stimulus
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Hoheisel U, Mense S, Simons DG.
Neurosci lett 153:9-12, 1993
Expansion of Receptive Field by a Painful Muscle Stimulus
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Hoheisel U, Mense S, Simons DG
Neurosci lett 153:9-12, 1993
15 min after BK injection in the TA the selected
neuron responds to moderate (innocuous) pressure in its original receptive field -
biceps femoris
Expansion of Receptive Field by a Painful Muscle Stimulus
Allodynia (light pressure and muscle
movement)
Hyperalgesia
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Glutamate Substance P
Nociceptive Bombardment causes
Central Sensitization and Neuroplastic
Changes in Dorsal Horn Neurons
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Pain begins in Calf, Heel and Foot
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Then Develops Pain in SI Joint too
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Then Develops Pain in SI Joint too
TrP3
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Ineffective Synapse
Dorsal horn
Neuron for SI Joint is Initially Inactive
TrP3
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Effective synapse
Expansion of the Receptive Field
TrP3
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Wide Dynamic Range Neuron
++----
Excitatory tonus via nociceptors
Inhibitory tonus
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Dynorphin
Met Leu- enkephalin
SP
Galanin
VIP
NPY
SOMGABA, Glycine, Glutamate, ACh, DA, 5-HT, Nitric Oxide
Immune system
Neurotrophins
Neurosteroids
Cytokines
Glia and Astrocytes
Substances Dynamically Modulating Dorsal Horn Neurons
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MTrPs and the Local Twitch Response
Courtesy Joseph Audette
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FibrositisMyositis
MyofascialPain
MyofascitisMyofibrositis
Muscularrheumatism Myelosis
Radiculitis
Myofascial Pain Historical and Regional Confusion
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Historical Context of Trigger Points
•
Steindler coined the term “trigger points” when he found he was able to relieve
sciatica by injecting Novocain into tender points in muscles in the lumbar and gluteal regions
•
Travell added the term “myofascial”
after performing a biopsy of the infraspinatus muscle and observed that pinching the fasciae produced the same referral pattern as the muscle
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Opening of Previously Ineffective Synapses
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Treatments for Myofascial Pain
•
Spray/Stretch•
Strain/counterstrain
•
Muscle energy•
Myofascial release
•
Medications•
Dry Needling
•
Trigger point injections•
Botox injections
•
Orthotics, shoe modification
•
Counseling•
Behavioral management
•
Relaxation•
Imagery
•
Hypnosis•
Coping skills
•
Acupressure
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“Dry needling MTrPs and eliciting LTRs is as effective as
lidocaine injection in inactivating a MTrP and relieving pain”
Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256-63.
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Recent studies comparing MTrP injections with a syringe and MTrP needling with an acupuncture needle showed that MTrP needling with an acup
needle does not cause more post-needling soreness
Ga H, Choi JH, Park CH, Yoon HJ. Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients - a randomised trial. Acupunct Med. 2007 Dec;25(4):130-6.
Ga H, Koh HJ, Choi JH, Kim CH. Intramuscular and nerve root stimulation vs lidocaine injection to trigger points in myofascial pain syndrome. J Rehabil Med. 2007 May;39(5):374-8.
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Trigger Point Needling: Trigger Point Needling: Proper Technique to Elicit Local Twitch Proper Technique to Elicit Local Twitch
Responses is EssentialResponses is EssentialHong CZ
Arch Phys Med Rehab 1994;73:256
Courtesy Joseph Audette
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How does dry needling work?
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What is the Pathophysiology of Myofascial Pain?
UNKNOWN
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Simons’ Integrated Hypothesis
Increased Miniature Endplate Potentials
(Endplate Noise)
Increased Fiber Tension (Taut Band)
Release of Sensitizing
Substances? (Pain)
Pathophysiology Histopathology
Histochemistry
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What is the Biochemical Milieu of MTrPs?
Clinical findings
Underlying milieu?
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Myofascial Trigger Points: A Unique Perspective at the NIH
In Vivo Microdialysis –
A Technique For Analysis of the Biochemical Milieu of MTrPs
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MicrodialysisLow or no solute
High concentration solute
Semi-permeable membrane
Courtesy Terry Phillips
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Microdialysis/Acupuncture Needle
Courtesy Terry Phillips
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Microdialysis/Acupuncture Needle –
30 Gauge Hypodermic
Fluid in
Fluid outSolute exchange
surface –
dialyzer membrane set 0.2 mm from the needle tip
Delivery tubes
Courtesy Terry Phillips
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Comparison of Needle Tips
25G syringe needle
32G acupuncture needle
Courtesy Terry Phillips
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Comparison between a Standard Acupuncture Needle and
our Needle/Probe
Acupuncture needle
Needle/Probe
Courtesy Terry Phillips
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Comparison of Needle Tips
Rounded acupuncture needle tip pushes cells aside rather than piercing them
Sharp beveled hypodermic needle tip acts like a miniature scalpel capable of piercing, cutting and tearing cells
Courtesy Terry Phillips
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Microdialysis Sampling
Courtesy Sagar Parikh
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Microdialysis System
Fraction collector
Soft tissue
Needle
In-flow catheter
Microdialysis pump
Out- flow
catheter
Courtesy Terry Phillips
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computer
detector
CE chamber
capillary
Power supply
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Co-investigators
•
Terry Phillips, PhD, DSc
•
Jerome Danoff, PT, PhD
•
Lynn Gerber, MD
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Hans-Werner Weisskircher www.trigger-
point.com
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Design, Setting, and Patients
Three healthy subjects were selected to be in each of three groups (total 9 subjects) based on history and physical examination of upper trapezius:
•
Group 1)
Normal (no neck pain, no trigger point)•
Group 2)
Latent (no neck pain, trigger point
present)•
Group 3)
Active (neck pain present [<
3months],
trigger point present).
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Initial Analyte Values in TrapeziusAnalyte Active Latent Normal *P value
pH (pH units) 5.4 6.3 6.5 P<.03
Bradykinin (pm/l) 69 49.6 47.5 P<.01
NE (nmol/l) 3.1 2.0 1.8 P<.01
Serotonin (nmol/l) 6.6 4.7 4.1 P<.01
Substance P (pg/ml) 187 50 34 P<.01
CGRP (pg/ml) 172 37.4 25.5 P<.01
TNF-α
(pg/ml) 173.5 26.5 21.2 P<.001
IL-1β
(pg/ml) 133.7 19.5 17.7 P<.001
*Active >
Latent, Normal (except pH)
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0
50
100
150
200
250
300
350
400
0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48
Time
pg/m
lConcentration of Substance P over time
I = SEEI
II
Active
Latent
Normal
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• Collect near real-time samples from soft tissue with minimal system perturbation and without harmful effects on subjects
• Proof-of-principle of the system’s ability to distinguish among subjects who have clinically distinct soft tissue findings
• Active MTrP in the upper trapezius has elevated levels of inflammatory mediators
(bradykinin,
protons, etc.), catecholamines
(norepinephrine and serotonin), neuropeptides
(substance P, CGRP)
and pro-inflammatory
cytokines
(TNF-α, IL-1β)
First Phase: What We’ve Demonstrated
Shah J, Phillips T, Danoff J, Gerber L. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005
99(5): 1977-84.
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1) Determine whether these findings are unique to the upper trapezius when compared to a remote uninvolved site in the medial gastrocnemius muscle
2) Measure additional analytes (e.g., IL-6 and IL-8) known to be associated with pain, inflammation and intercellular signaling.
Purpose of Second Phase
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9 subjects, all of whom had no calf pain or calf MTrPs, were divided into 3 groups based on the following findings in the trapezius:
1) Active (painful MTrP present; 3 subjects) 2) Latent (non-painful MTrP present; 3 subjects) 3) Normal (no pain, no MTrP present; 3 subjects)
Design, Setting, and Patients
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Hans-Werner
Weisskircher
www.trigger-
point.com
3 Groups of Subjects with following findings in upper trapezius muscle:
1) Active MTrP, 2) Latent MTrP, 3) No MTrP
No MTrP
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Exclusion Criteria
•
Fibromyalgia•
Cervical radiculopathy
•
Atypical facial neuralgia•
History of previous trigger point injections in the upper trapezius and upper medial gastrocnemius
•
Knee pain•
History of cervical spine or shoulder surgery
•
On any medications
•
Other concurrent pain syndromes
•
Use of tobacco products•
Any aspirin within 3 days of needling
•
History of bleeding diatheses•
Being on anticoagulation therapy
•
An inordinate fear of needles•
Lumbosacral radiculopathy
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Procedure and MeasuresProcedure :Samples were obtained continuously from the trapezius site at regular intervals for 14 minutes, and then from the upper medial gastrocnemius site for 10 minutes.
Measures :Levels of protons (H+), bradykinin, SP, CGRP, serotonin, norepinephrine, TNF-α, IL-1β, IL-6 and
IL-8.
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Initial Analyte Values in TrapeziusAnalyte Active Latent Normal *P valuepH (pH units) 5.2 6.6 6.7 P<.001Bradykinin (pm/l) 71.3 39.9 41.5 P<.003NE (nmol/l) 3.0 1.9 1.5 P<.0001Serotonin (nmol/l) 6.9 4.2 3.9 P<.0001Substance P (pg/ml) 169.3 46.7 30.8 P<.0001CGRP (pg/ml) 157.3 49.3 25.8 P<.0001TNF-α
(pg/ml) 181.8 30.0 8.9 P<.001IL-1β
(pg/ml) 121.9 20.8 9.9 P<.001IL-6 (pg/ml) 130.2 16.7 10.5 P<.0001IL-8 (pg/ml) 61.7 7.7 6.9 P<.0001
*Active >
Latent, Normal (except pH)
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0.00
100.00
200.00
300.00
400.00
500.00
600.00
0.00 5.00 10.00 15.00
Time (min)
pg/L
Set 1 Active
Set 1 Latent
Set 1 Normal
Set 2 Active
Set 2 Latent
Set 2 Normal
Combined Data for Substance P Concentration in Trapezius over Time
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Concentrations of Analytes in the Active Group at Initial Needle Insertion
Analyte Trap GS *P valuepH 5.5 5.7 NS
Bradykinin 63.7 39.7 P<.001
NE 2.8 2.4 P<.001Serotonin 6.5 6.0 P<.001Substance P 140.9 52.9 P<.001
CGRP 129.9 46.7 P<.001TNF-α 143.9 45.5 P<.001 IL-1β 97.1 44.8 P<.001 IL-6 102.5 39.6 P<.001IL-8 48. 8 21.5 P<.001
*Trapezius >
Gastrocnemius
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Analyte GS (Act) GS (Lat) GS (Nor) *P valuepH 5.7 6.7 6.8 P<.01
Bradykinin 39.7 37.4 35.3 P<.01(A>N)
NE 2.4 1.8 1.5 P<.01
Serotonin 6.0 4.4 3.7 P<.01
Substance P 52.9 18 13.8 P<.01
CGRP 46.7 16.1 12.1 P<.01
TNF-α 45.5 17.1 8.6 P<.01
IL-1β 44.8 23.1 8.5 P<.01
IL-6 39.6 14.9 9.5 P<.01
IL-8 21.5 10.5 5.5 P<.01
Concentrations of Analytes at Initial Needle Insertion in Gastrocnemius Muscle
*Active >
Latent, Normal (except pH)
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Active
Latent
NormalActive group
I = SEE
(Normal Muscle)
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Active
Latent
Normal
I = SEE
(Normal Muscle)
Active group
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I = SEEActive
(Normal Muscle)
Active grou
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ActiveI = SEE
(Normal Muscle)
Active group
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I = SEE
Active
e
(Normal Muscle)
Active group
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e
I = SEE
Active Active group
(Normal Muscle)
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• An active MTrP has a unique biochemical milieu of substances known to be associated with pain states and inflammation
• The biochemical milieu of an active MTrP in the upper trapezius differs quantitatively from a remote, uninvolved site in the gastrocnemius muscle.
Second Phase: What We’ve Learned
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• Subjects with an active MTrP in the upper trapezius have elevated levels of these analytes in a remote, uninvolved muscle compared to latent and normal subjects. This suggests that substances associated with pain are not limited to local areas of MTrPs or a single anatomical locus.
• In the trapezius, the concentration of specific analytes dramatically changes in response to initial needle insertion and also following a local twitch response, particularly in active MTrPs
Second Phase: What We’ve Learned
Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, Gerber LH. Biochemicals assoicated with pain and inflammation are elevated in sites near to and
remote from active myofascial trigger points. Archives of Physical Medicine & Rehabilitation 2008 Jan;89(1):16-23
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Biochemical Considerations
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H+
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“Pro-inflammatory cytokines increase the sensitivity of all
peripheral neural structures and their afferent cell bodies, causing
hyperalgesia and the development of neuropathic pain
states”Cytokines and Pain. Watkins
and Maier, eds. 2000
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Hypernociceptive role of cytokines and chemokines:
Targets for analgesic drug development?
Verri WA, Cunha TM, Parada CA et alPharmacology and Therapeutics 2006
TNF-α, IL-1β,
IL-6 and IL-8 were among the first cytokines described as participating in the development of
inflammatory and neuropathic pain
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Cg, LPS or Ag
Nociceptor Sensitization
IL-1β
↔IL-6
Cytokine Cascade and Pain
TNF-α
Prostaglandins
IL-8 ↔CINC-1
Sympathetic amines
Ag
IL-18 ↔ IL-12
ET-1
Verri WA et. alPharmacology and Therapeutics 2006
Cox enzyme β-Blocker
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50-μm laser-drilled hole for embedding hydrogel
Second Generation Needle with Hydrogel
First Generation Microdialysis Needle
Moving Ahead: Microanalytic Systems for in-vivo Measurement of the Biochemical Milieu of Muscle
Shah et al. J. Appl. Physiol. 2005 99:1977-94
30-gauge needle~0.5 μL sample
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The Next Phase: A Natural History Study
• Does the biochemical milieu at and around the MTrP change with respect to the natural history of myofascial pain in the upper trapezius?
• Does the biochemical milieu of the upper trapezius correlate with changes in the severity of pain, presence or absence of physical findings or degree of local tenderness over time?
• What are the levels of anti-inflammatory substances (e.g., IL-4, IL-10), neurotrophins (e.g., NGF, NT-3), analgesic substances (e.g., β-endorphin) and substances associated with muscle metabolism and physiology (e.g., creatine kinase, aldolase, ACh esterase, etc.)?
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Treatment TrialsAssess the local biochemical milieu of MTrPs as an outcome measure
of efficacy in clinical treatment trials utilizing
pharmacologic and physical medicine approaches
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A New Direction
To Address an Old Controversy
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Obstacles
•
There are currently no imaging criteria for the diagnosis of trigger points or for assessing clinical outcome of treatments.
•
It remains a clinical diagnosis based exclusively on history and physical examination.
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Our Research Question
In the long term, we want to understand the pathophysiology of myofascial pain and develop
clinical outcome measures.
Can ultrasound imaging be used to develop objective descriptions of the tissue and blood flow characteristics of
myofascial trigger points (MTrPs) and the immediately adjacent structures?
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Hypoechoiec trigger point
3 cm
Fascia
Uppertrapezius
Upper Trapezius Muscle with MTrP
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Vibration Sonoelastography
30 kPa
63 kPa 44 kPa
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Vibration Applicator
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Hypoechoeic trigger
point
Focal decrease of color
variance indicates a
localized stiffer region
upper trapezius
Vibration Sonoelastography of Muscle with MTrP
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Uniform echogenecity in
uninvolved muscle
Uniform color variance
indicates homogeneous
stiffness
upper trapezius
Vibration Sonoelastography of Uninvolved Muscle
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Vibration Sonoelastography of Uninvolved Muscle
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Sonoelastography Imaging
Objective diagnostic test
Outcome measure to evaluate tissue changes in response to treatment
Describe natural history
Sikdar et al. Arch. Phys. Me Rehabil., 2009 (in press)
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Imaging blood flow near MTrPs in the Upper Trapezius
B BFS=1
A BFS=0
BFS=2D
BFS=2C
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• Ultrasound is feasible for imaging MTrPs
• MTrPs exhibit different echogenecity compared to surrounding muscle.
• Vibration sonoelastography shows differences in relative stiffness between trigger points and normal (uninvolved) muscle. Sikdar et al. Assessment of Myofascial Trigger Points (MTrPs): A
New Application of Ultrasound Imaging and Vibration Sonoelastography. Conf Proc. IEEE Eng Med Biol Soc. 2008
Observations
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Observations•
Blood flow waveform characteristics can be used to differentiate Active and Latent MTrPs
•
Retrograde flow in diastole indicating a very high resistance vascular bed and possible blood vessel compression is associated with Active MTrPs Sikdar S, Shah JP, Gebreab T, Yen R, Gilliams E, Danoff J, Gerber L. Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Point and Surrounding Soft Tissue. Archives of Physical Medicine and Rehabilitation. In press. 2009
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XXInflamatory
Mediators, BK,NE, SP,
Serotonin, Cytokines
Integrated
Neuromuscular
Theory
Courtesy Bryan O’Neill
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Injection Therapies
What?Where? Why?