Ana Isabel de-la-Llave-Rincón

Immediate Changes in Widespread Pressure Pain Sensitivity, Neck Pain, and Cervical Range of Motion After Cervical or Thoracic Thrust Manipulation in Patients With Bilateral Chronic Mechanical Neck Pain: A Randomized Clinical Trial

STUDY DESIGN Randomized clinical trial. OBJECTIVES To compare the effects of cervical versus thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity, neck pain, and cervical range of motion (CROM). BACKGROUND Evidence suggests that spinal interventions can stimulate descending inhibitory pain pathways. To our knowledge, no study has investigated the neurophysiological effects of thoracic thrust manipulation in individuals with bilateral chronic mechanical neck pain, including widespread changes on pressure sensitivity. METHODS Ninety patients (51% female) were randomly assigned to 1 of 3 groups: cervical thrust manipulation on the right, cervical thrust manipulation on the left, or thoracic thrust manipulation. Pressure pain thresholds (PPTs) over the C5-6 zygapophyseal joint, lateral epicondyle, and tibialis anterior muscle, neck pain (11-point numeric pain rating scale), and cervical spine range of motion (CROM) were collected at baseline and 10 minutes after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of covariance were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable, time and side as the within-subject variables, and gender as the covariate. The primary analysis was the group-by-time interaction. RESULTS No significant interactions were found with the mixed-model analyses of covariance for PPT level (C5-6, P>.210; lateral epicondyle, P>.186; tibialis anterior muscle, P>.268), neck pain intensity (P = .923), or CROM (flexion, P = .700; extension, P = .387; lateral flexion, P>.672; rotation, P>.192) as dependent variables. All groups exhibited similar changes in PPT, neck pain, and CROM (all, P<.001). Gender did not influence the main effects or the interaction effects in the analyses of the outcomes (P>.10). CONCLUSION The results of the current randomized clinical trial suggest that cervical and thoracic thrust manipulation induce similar changes in PPT, neck pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain. However, changes in PPT and CROM were small and did not surpass their respective minimal detectable change values. Further, because we did not include a control group, we cannot rule out a placebo effect of the thrust interventions on the outcomes. LEVEL OF EVIDENCE Therapy, level 1b.J Orthop Sports Phys Ther 2012;42(9):806-814, Epub 18 June 2012. doi:10.2519/jospt.2012.4151.

Response of Pain Intensity to Soft Tissue Mobilization and Neurodynamic Technique: A Series of 18 Patients With Chronic Carpal Tunnel Syndrome

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.

Muscle trigger point therapy in tension-type headache.

Recent evidence suggests that active trigger points (TrPs) in neck and shoulder muscles contribute to tension-type headache. Active TrPs within the suboccipital, upper trapezius, sternocleidomastoid, temporalis, superior oblique and lateral rectus muscles have been associated with chronic and episodic tension-type headache forms. It seems that the pain profile of this headache may be provoked by referred pain from active TrPs in the posterior cervical, head and shoulder muscles. In fact, the presence of active TrPs has been related to a higher degree of sensitization in tension-type headache. Different therapeutic approaches are proposed for proper TrP management. Preliminary evidence indicates that inactivation of TrPs may be effective for the management of tension-type headache, particularly in a subgroup of patients who may respond positively to this approach. Different treatment approaches targeted to TrP inactivation are discussed in the current paper, focusing on tension-type headache. New studies are needed to further delineate the relationship between muscle TrP inactivation and tension-type headache.

Prevalence and Anatomical Localization of Muscle Referred Pain from Active Trigger Points in Head and Neck Musculature in Adults and Children with Chronic Tension-Type Headache

OBJECTIVE To compare differences in the prevalence and the anatomical localization of the referred pain areas of active trigger points (TrPs) in head and neck musculature between adults and children with chronic tension-type headache (CTTH). DESIGN A cross-sectional study. SETTING Some studies had found that referred pain from active TrPs reproduce the head pain pattern in adults. No study has compared clinical differences between referred pain patterns elicited by active TrPs between adults and children with CTTH. PATIENTS Twenty adults (10 men, 10 women, mean age: 41 ± 11 years) and 20 children (10 boys, 10 girls, mean age: 8 ± 2 years) with CTTH were included. OUTCOME MEASURES Bilateral temporalis, sternocleidomastoid, upper trapezius, and suboccipital muscles were examined for TrPs. TrPs were identified by palpation and considered active when local and referred pains reproduce the headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured. An analysis technique based on a center of gravity (COG) method was used to provide a quantitative estimate of the localization of the TrP referred pain areas. RESULTS Adults with CTTH exhibited a greater years with headache, higher intensity, and longer headache duration (P < 0.05) compared with children. The COG coordinates of the spontaneous pain on the dominant side were located more anterior (higher X-value), and spontaneous pain in the frontal and posterior areas was located more inferior (lower Y-value) in adults than in children. The number of active muscle TrPs was significantly higher (P = 0.001) in adults with CTTH (mean ± standard deviation [SD]: 4 ± 0.8) as compared with children (mean ± SD: 3 ± 0.7). Children with CTTH had larger referred pain areas than adults for upper trapezius, sternocleidomastoid, and temporalis (P < 0.001) muscles. The COG coordinates of the referred pain areas of temporalis and sternocleidomastoid muscle TrPs were more inferior (lower Y-values) in adults than in children with CTTH. CONCLUSIONS This study showed that the referred pain elicited from active TrPs shared similar pain patterns as spontaneous CTTH in adults and children. Differences in TrP prevalence and location of the referred pain areas can be observed between adults and children with CTTH.

Alteration in sleep quality in patients with mechanical insidious neck pain and whiplash-associated neck pain.

ObjectiveThis study aimed to determine differences in sleep quality between patients with mechanical neck pain, patients with whiplash (WAD) pain, and healthy controls and to determine the relationship between the intensity of ongoing pain, disability, and sleep quality. DesignNineteen patients with mechanical neck pain (4 men, 15 women; age, 40 ± 16 yrs), 22 with WAD (4 men, 18 women; age, 38 ± 15 yrs), and 18 comparable controls (4 men, 14 women; age, 41 ± 13 yrs) completed the Pittsburgh Sleep Quality Index to assess sleep quality. A numerical pain rate scale (0–10) and the Neck Disability Index (0–50) were collected for assessing neck pain and disability. ResultsSignificant differences in sleep quality (P < 0.001), sleep latency (P = 0.005), sleep efficiency (P = 0.002), sleep disturbances (P < 0.001), use of sleeping medication (P < 0.001), daytime dysfunction (P < 0.001), and total Pittsburgh Sleep Quality Index score (P < 0.001) but not for sleep duration (P = 0.096) were found; patients with mechanical neck pain and WAD pain exhibited higher scores in all components compared with healthy controls. Seventeen (77%) patients with WAD and 13 (68%) with mechanical neck pain reported poor sleep quality (Pittsburgh Sleep Quality Index score, >8). Significant positive correlations between mean intensity of ongoing pain with sleep quality (rs = 0.693; P < 0.001); sleep duration (rs = 0.433; P = 0.044); sleep efficiency (rs = 0.644; P = 0.001) and total Pittsburgh Sleep Quality Index score (rs = 0.643; P = 0.001) were found in patients with WAD pain; the higher the intensity of ongoing pain, the worse the sleep quality. ConclusionsSleep disturbances are a common finding in individuals with neck pain and are associated with the intensity of ongoing pain in WAD. It seems essential to address the ongoing cycle of pain and sleep disturbances as an integral part of the treatment of patients with neck pain.

Myofascial Trigger Points in the Masticatory Muscles in Patients With and Without Chronic Mechanical Neck Pain

OBJECTIVES The purpose of this study is to describe differences in the presence of masseter and temporalis muscle trigger points (TrPs) and jaw opening between individuals with mechanical neck pain and healthy controls. METHODS Twenty patients with mechanical neck pain (60% women) without symptoms in the orofacial region, aged 20 to 37 years old, and 20 matched controls participated. Temporalis and masseter muscles were examined for the presence of TrPs in a blinded design. Trigger points were considered active if the subject recognized the pain as a familiar symptom, whereas the TrPs was considered latent if the pain was not recognized as a symptom. Jaw opening was assessed with a ruler. RESULTS A greater number (P < .001) of TrPs in the masticatory muscles were found in patients than in controls. None of the patients or healthy controls recognized the referred pain as familiar; thus, latent rather than active TrPs were found. The distribution of TrPs between groups was different for the masseter (left odds ratio [OR], 3.4; right OR, 8.1; P < .001) and temporalis (left OR, 2.8; right OR, 5.7; P < .001) muscles. Patients with neck pain had smaller jaw opening than controls (P < .001). A negative correlation between active jaw opening and the number of TrPs within the masticatory muscles (r(s) = -0.6; P < .001) was found: the greater the number of TrPs, the smaller the jaw opening. CONCLUSIONS For the subjects in this study, those with mechanical chronic neck pain had more latent TrPs in the masticatory muscles and reduced jaw opening compared to healthy controls. These findings may suggest the spread of sensitization from the cervical segment to the trigeminal brain stem sensory nuclear complex.

Genetic Contribution of Catechol- O -Methyltransferase Polymorphism (Val158Met) in Children With Chronic Tension-Type Headache

Our aim was to investigate the relationship between Val158Met polymorphisms, headache, and pressure hypersensitivity in children with chronic tension-type headache (CTTH). A case–control study with blinded assessor was conducted. Seventy children with CTTH associated with pericranial tenderness and 70 healthy children participated. After amplifying Val158Met polymorphism by polymerase chain reactions, we assessed genotype frequencies and allele distributions. We classified children according to their Val158Met polymorphism: Val/Val, Val/Met, Met/Met. Pressure pain thresholds (PPT) were bilaterally assessed over the temporalis, upper trapezius, second metacarpal, and tibialis anterior muscles. The distribution of Val158Met genotypes was not significantly different (p = 0.335), between children with CTTH and healthy children, and between boys and girls (p = 0.872). Children with CTTH with the Met/Met genotype showed a longer headache history compared with those with Met/Val (p = 0.001) or Val/Val (p = 0.002) genotype. Children with CTTH with Met/Met genotype showed lower PPT over upper trapezius and temporalis muscles than children with CTTH with Met/Val or Val/Val genotype (p < 0.01). The Val158Met catechol-O-methyltransferase (COMT) polymorphism does not appear to be involved in predisposition to suffer from CTTH in children; nevertheless, this genetic factor may be involved in the phenotypic expression, as pressure hypersensitivity was greater in those CTTH children with the Met/Met genotype.

Deep Tissue Hypersensitivity to Pressure Pain in Individuals with Unilateral Acute Inversion Ankle Sprain

OBJECTIVE The objective of this study was to investigate whether pressure hypersensitivity over deep tissues is a feature of acute inversion ankle sprain. DESIGN This is a cross-sectional study. SETTING No study has previously investigated peripheral and central sensitization mechanisms in a clinical acute pain model such as inversion ankle sprain. PATIENTS Twenty individuals with unilateral inversion ankle sprain (10 women/10 men, age: 31 ± 7 years) and 19 comparable healthy controls (11 women/8 men, age: 30 ± 6 years) participated in this study. OUTCOMES Pressure pain thresholds (PPTs) over anterior talofibular, calcaneofibular, and deltoid ligaments; the lateral and medial malleolus; the tibialis anterior muscle; second metacarpal; and median, radial, and ulnar nerves were bilaterally assessed. RESULTS The analysis of variance (ANOVA) revealed that PPT levels over the affected anterior talofibular (P = 0.048) and calcaneofibular (P = 0.002) ligaments, and over the affected lateral malleolus (P < 0.001) were lower compared with the non-affected side within patients and both sides in controls. The patients also showed bilateral lower PPT levels over the deltoid ligament than controls (P < 0.05). No significant differences for PPT over the medial malleolus; the second metacarpal; the tibialis anterior muscle; and the median, ulnar, radial nerves were found. Significant negative correlations between intensity of ongoing pain and PPT over the anterior talofibular and deltoid ligaments were found: the higher the pain intensity, the lower the PPT. CONCLUSIONS This study showed the presence of localized pressure pain hypersensitivity over ankle ligaments in patients with unilateral acute inversion ankle sprain, confirming the presence of localized peripheral sensitization.

Pain is Associated to Clinical, Psychological, Physical, and Neurophysiological Variables in Women With Carpal Tunnel Syndrome.

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.

Comparison of Third-Year Medical and Physical Therapy Students' Knowledge of Anatomy Using The Carpal Bone Test

OBJECTIVE The curricula of all health professionals have an important foundation of human anatomy. A comparison of the anatomy retention between students from different curricula has not been studied. Our aim was to examine the knowledge competency of third-year physical therapy and medical students in carpal bone anatomy. METHODS The testing was conducted on the third-year medical and physical therapy students at Universidad de Granada. Students were given 5 minutes to answer the carpal bone test, a test which requires the identification of the carpal bones in an illustration of the bony skeleton of carpal region. Differences in the distribution of the responses between groups were analyzed using the χ(2) test. RESULTS One hundred thirty-four (n = 134) tests were analyzed (n = 54 [41%] physical therapy students, n = 80 [59%] medical students). Only 39 students correctly identified all of the carpal bones (42.6% physical therapy, 20% medical, P < .001). Physical therapy students correctly identified a greater number (P < .001) of carpal bones (mean ± SD, 5.8 ± 2.2) than medical students (mean ± SD, 3.1 ± 2.9). The capitate was the most frequently identified bone in both physical therapy (96%) and medical (46%) students (P < .001). The hamate bone was the least frequently identified bone by medical students (n = 29, or 36.3%), whereas the trapezoid bone was the least frequently identified bone by physical therapy students (n = 35, or 64.8%). CONCLUSION There are few studies investigating anatomical knowledge levels between disciplines. This study found that physical therapy students exhibited better retention of anatomy of the carpal bones than medical students.