Adjunctive Therapy for Myofascial Pain Syndrome

The lead article for this issue of the Journal of Musculoskeletal Pain [JMP] comes from investigators in Gaziantep, Turkey (1). The authors proposed to evaluate the efficacy of ultrasound [10 sessions] versus extracorporeal shock wave therapies [three sessions] in patients with myofascial pain syndrome [MPS] involving the trapezius muscle on at least one side of the body. They made the diagnosis of MPS according to the criteria of Simons and Travell (2). Their approach involved a controlled clinical trial in which 66 selected MPS patients were randomized to one of two treatment groups. Wisely, patients with comorbid fibromyalgia syndrome [FMS] were excluded. Evaluations were conducted at 3 weeks and 3 months by an examiner blinded to the randomization code. The patients tolerated both of the therapies and there were no severe complications. Statistically significant improvement was observed. Readers are advised to see the authors’ data to determine whether one of these interventions was favored by the experiment and whether the findings of this experiment will inform future choices of a physical modality for treatment of MPS.

The second original contribution in this issue, relating to treatment of MPS, comes from Ankara, Turkey (3). This study was designed to determine whether a form of audio biofeedback would augment the treatment of MPS. They made the diagnosis of MPS according to the criteria of Simons and Travell (2). Patients with comorbid FMS were excluded. The authors recruited 90 patients with MPS involving the upper trapezius muscle on at least one side of the body and randomly assigned them into two intervention groups. Sixty of those patients [30 per intervention group] completed the study. The experimental group was instructed to use a portable audio biofeedback device for 30 min twice a day in addition to complying with a home-based exercise program. The control group received only the home-based exercise program. The home-based exercise program included neck isometric-isotonic exercise, back extensor stretching exercise, and posture exercises which were to be accomplished five times a week for 4 weeks, performing 15 repetitions of each exercise once daily. Outcome measurements were taken before starting therapy and after 4 weeks of therapy. The severity of the patient’s pain was measured by a visual analog scale. The number of trigger points, pressure pain threshold, cervical joint range of motion, and head–shoulder angles were recorded. Disability was assessed by the Neck Pain Disability Scale. Statistically significant improvements were observed in this study, including some differences in outcome between the experimental treatment and control groups. Readers are advised to see the authors’ data to determine whether the magnitude of these differences should prompt clinicians to add audio biofeedback to the exercise protocols they order for MPS patients with the objective of achieving specific outcome benefits.

An uncontrolled pilot study conducted in Boston, MA, USA has reported the effects of a pain-specific relaxation response resiliency enhancement program [R3P, eight group sessions] for the management of chronic refractory temporomandibular joint disorder of the MPS type, involving the masticatory muscles (4). Twenty-four subjects [16 females], mean age 38 years, with at least a 6-month history of temporomandibular joint disorder completed the study between 2008 and 2010. Eligible participants underwent the R3P intervention after completing a standard medical management program. Pre- and post-intervention assessments included measures of impairment [vertical and lateral range of motion with and without pain, and temporomandibular joint and muscle pain palpation and algometry measures] and completed psychosocial measures [Symptom Severity Index, Perceived Stress Scale, the Symptom Checklist-90-Revised, and Short Form 36 Health Survey]. The authors’ data would indicate that the experiment was a success, so a randomized, controlled clinical trial was inaugurated. Transportability of such a program to other locations may depend largely upon the local availability of the many clinical resources offered by the R3P.

A report from a collaboration between investigators in Ankara, Turkey and Leeds, UK summarizes the reliability, construct validity, and measurement potential of the International Classification of Functioning, Disability, and Health Comprehensive Core Set for Chronic Widespread Pain (5). Readers of the JMP will recognize the term “chronic widespread pain” [CWP] as a generic equivalent to the generic term “generalized soft tissue pain” proposed as part of a pain classification scheme outlined in an earlier issue of the JMP (6). The term CWP has been adopted in some scientific circles as being more acceptable than the term “fibromyalgia syndrome”, but those who favor the CWP term often view FMS as the most severe form of CWP (5,7). In this article, data are provided to examine the core domains of CWP as represented by FMS patients. The authors explain that the ICF Comprehensive Core Set for CWP consists of 23 categories from the component Body Functions, one from Body Structures, 27 from Activities and Participation, and 16 from Environmental Factors. The recruitment of FMS patients for this data gathering exercise was accomplished in Ankara, Turkey, so it was necessary to use validated Turkish translations of the core and comparison instruments. The authors’ article provides much data regarding outcomes of the various components of the core instrument, regarding the Rash analysis of the data, and regarding comparisons with other commonly used instruments, such as the Fibromyalgia Impact Questionnaire and Short Form-36. The authors of this work have contributed substantially to the progress of standardized assessment of patients with CWF and FMS. They discuss limitations of their work and focus appropriately on sample size issues. Another important aspect of this study is the fact that the patients all came from one unique culture which may have a very different view of CWP, FMS, or disablement than might be true of other world cultures. We could wonder whether the selected core items and the subscores derived from the International Classification of Functioning, Disability, and Health Comprehensive Core Set for CWP would have been much the same or substantially different, had the study had been conducted with FMS patients from a Scandinavian, western European, South American, or African culture.

The relationship between mild musculoskeletal pain and health-related quality of life was explored in a report from Izmir, Turkey (8). Once in a while, a small, unfunded study with a good idea and careful execution will reveal something fairly new and important to understand. That seems to have been the case with this study. The investigators recruited apparently healthy 45 year old, or older, relatives of hospitalized patients when they came to visit. The study team sought evidence for musculoskeletal pain among the recruited subjects and found mild musculoskeletal pain among some of them while others had not experienced musculoskeletal pain. They then examined both groups for their health-related quality of life, their exercise capacity, and other measures. The results identified a category of suffering seldom recognized or studied. The authors discussed the implications of their findings and offered suggestions regarding where to go from here.

An interesting assessment of post-exercise hypoalgesia comes from Athens, GA, USA (9). In this experiment, eccentric exercise was utilized as a noxious stimulus capable of inducing muscle injury-related pain, while heat pain threshold was used as the test for pain sensitivity. The control exercise was concentric exercise that did not cause muscle injury or pain. Eighteen women from 18 to 34 years of age were allocated to the two exercise intervention groups; 12 in the concentric exercise group and six in the control exercise group. The reason for the 2:1 ratio between the two intervention groups was to allow the concentric exercise group to be populated by a nearly equal number of women with either red-hair/light-complexion or women with dark-hair/dark-complexion. The reader is encouraged to carefully review the investigators’ data to see if eccentric exercise is sufficiently noxious to raise the cutaneous heat/pain threshold and whether hair color is a marker for a genetically dependent modification of that phenomenon.

In a study reported from Tehran, Iran (10), the investigators proposed to determine which of three methods of dorsiflexion stretching of the ankle is best to acutely increase ankle flexibility. Female professional taekwondo athletes were randomly allocated into three intervention protocol groups [active warm-up, passive warm-up or static stretching]. Before and immediately after completing each of the stretching protocols, study participants were examined with a goniometer to determine their ankle dorsiflexion range of motion. Which method was most successful for these athletes? The authors clearly answer that question in their article and then discuss the results from their study in relationship to other published work in this concept.

Finally, clinician investigators from Poznan, Poland (11) have summarized their view of the medical literature in their review regarding the differences between FMS and MPS. They properly distinguish the two conditions from each other, associating the term “tender points” with the central neuropathic condition called FMS and the term “trigger points” with the condition of peripheral skeletal muscles, MPS. At the same time, the authors acknowledge that the two conditions can coexist, and by so doing, can add to clinician’s difficulty with clinical diagnosis.

Since there were so many interesting research reports available to this issue, there was no room for Case Reports, Research Ideas or Book Report contributions.

Please note the special interest columns which provide brief reviews of articles published in other medical journals since the previous issue of the JMP. The topical categories of these reviews are FMS, MPS and other soft tissue pain syndromes.

As always, readers of the JMP are invited to submit original manuscripts for blinded peer review, case reports of general interest, research ideas to promote further investigation, and letters to keep us all informed. The JMP editorial office frequently receives relevant books to be evaluated by and for the benefit of our readers. Book reviewers are allowed keep the featured book after their evaluation report is completed. Readers, who would be interested in being a book reviewer for the JMP, please communicate that to the editor [[email protected]]. Potential authors of contributions to the JMP should note that submissions and all communications between the authors and the JMP staff are to be accomplished online. Visit http://mc.manuscriptcentral.com/wjmp for more details.

The clear mandate of the International MYOPAIN Society [IMS], for which the JMP currently serves as the official journal, is to perpetuate the international meeting [MYOPAIN] that has been held every 3 years, but is moving soon to an every 2-year schedule. The next International MYOPAIN Meeting will be MYOPAIN 2013 which will be held in the beautiful Pacific seacoast town of Seattle, WA, USA. Dr Philip Mease, IMS Vice President and Program Chairman for the Seattle meeting has worked closely with the IMS Board to make plans for the Seattle meeting. Two years after that meeting, the International MYOPAIN 2015 Meeting will be held in the an elegant Pacific coast town of Sydney, Australia, as the IMS hopes to better serve our growing numbers of members from Asia and the Pacific Rim. The IMS website www.myopain.com will provide details.

Be aware that Regional IMS Chapters are beginning to form. The first to be officially organized was in Thailand. Please contact Pradit Prateepavanich, MD, PhD, [Department of Rehabilitation Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, e-mail: [email protected], [email protected]] if you wish to learn how.

In previous editorials, it was announced that Larry Bodkin was serving as the executive manager of the IMS, but unfortunately, Mr Bodkin proved untrustworthy. The new IMS administrator is Donna Cameron, CAE, President, Melby, Cameron & Anderson, 23607 Highway 99, suite 2C, Edmonds, WA 98026, USA; e-mail: [email protected]; http:mcamgmt.com; tel: [phone], fax: [phone]. One of Donna’s staff members, Melanie Rice, dedicates her time to getting IMS back on a solid foundation of responsible daily operations. The IMS website is www.myopain.org. Members are urged to pay their dues for 2013 because dues payment makes them eligible to receive the JMP. Dues payment and new member applications can be tendered via the www.myopain.org website. The current IMS Board Chairman is Bob Gerwin, MD, tel: [phone]; e-mail: [email protected]. If you have questions about anything pertaining to IMS, Donna Cameron and Melanie Rice will be able to provide the answers. Communications regarding IMS operations should be directed to Melanie Rice [[email protected]]. With Ms Cameron’s experienced leadership, we can expect growth and progress on many fronts.