Elżbieta Skorupska

Trigger point-related sympathetic nerve activity in chronic sciatic leg pain: a case study

Sciatica has classically been associated with irritation of the sciatic nerve by the vertebral disc and consequent inflammation. Some authors suggest that active trigger points in the gluteus minimus muscle can refer pain in similar way to sciatica. Trigger point diagnosis is based on Travel and Simons criteria, but referred pain and twitch response are significant confirmatory signs of the diagnostic criteria. Although vasoconstriction in the area of a latent trigger point has been demonstrated, the vasomotor reaction of active trigger points has not been examined. We report the case of a 22-year-old Caucasian European man who presented with a 3-year history of chronic sciatic-type leg pain. In the third year of symptoms, coexistent myofascial pain syndrome was diagnosed. Acupuncture needle stimulation of active trigger points under infrared thermovisual camera showed a sudden short-term vasodilatation (an autonomic phenomenon) in the area of referred pain. The vasodilatation spread from 0.2 to 171.9 cm2 and then gradually decreased. After needling, increases in average and maximum skin temperature were seen as follows: for the thigh, changes were +2.6°C (average) and +3.6°C (maximum); for the calf, changes were +0.9°C (average) and +1.4°C (maximum). It is not yet known whether the vasodilatation observed was evoked exclusively by dry needling of active trigger points. The complex condition of the patient suggests that other variables might have influenced the infrared thermovision camera results. We suggest that it is important to check if vasodilatation in the area of referred pain occurs in all patients with active trigger points.

The Effectiveness of the Conservative Versus Myofascial Pain Physiotherapy in Tennis Elbow Patients: Double-Blind Randomized Trial of 80 Patients

Objective The aim was to check usefulness of a conservative [C] or myofascial pain [MFP] approach in low-level laser therapy [LLLT] or ultrasound [US] therapy for patients with tennis elbow [TE], independent of the presence of trigger points [TrPs]. Methods Eighty patients [38 males, 42 females] with TE, in acute or subacute states, were randomly divided into four groups: LLLT-C, LLLT-MFP, US-C, or US-MFP. Doses of LLLT were 1 J/cm2 in the conservative group and 5 J/cm2 for each TrP related to TE in the MFP group. US: 0.5 W/cm2 3 MHz for conservative and 0.7 W/cm2 1 MHz on each TrP and each taut band. Evaluations of each patient at baseline and at the end of therapy [10 interventions] included: the presence and sensitivity of TrPs [algometer], level of pain [VAS], Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, and hand grip strength [dynamometer]. After one year of therapy, the patients were rechecked. Results Improvement of the VAS was 36.7 percent with LLLT-C, 36.9 percent with US-C, 48.4 percent with LLLT-MFP, and 55.4 percent with US-MFP [P < 0.005]. The Outcome of Disabilities of the Arm, Shoulder and Hand correlated with the VAS [r = 0.464]. Improvement of the grip strength was, respectively, 5.1 percent, 16.0 percent, 9.5 percent, and 109.0 percent for US-MFP [only US-MFP P < 0.01]. The only worsening of grip strength was after classic LLLT [−2.8 percent] among TrP-positive patients. TrPs were confirmed in 35 percent of patients. In that group, MFP methods were more effective than were conservative measures. After one year symptoms reappeared in 37.5 percent of patients. Conclusion We suggest that though both agents and both approaches for therapy of TE patients are equally effective, but the authors still favor US-MFP.

Intensive vasodilatation in the sciatic pain area after dry needling.

BackgroundShort-term vasodilatation in the pain area after dry needling (DN) of active trigger points (TrPs) was recorded in several cases of sciatica. Moreover, the presence of TrPs in sciatica patients secondary to primary lesion was suggested. Still, it is not known how often they occur and if every TrPs can provoke vasomotor reactions.The purpose of this study was to evaluate the prevalence of active TrPs among subacute sciatica patients and the response to DN under infrared thermovision (IRT) camera control.MethodFifty consecutive Caucasian patients (mean age 41.2 ± 9.1y) with subacute sciatica were diagnosed towards gluteus minimus TrPs co-existence. Based on TrPs confirmation, patients were divided into two groups: TrPs-positive and TrPs-negative, than DN under IRT control was performed. Skin temperature changes and the percentage size of vasomotor reactions in the pain area were evaluated if present.ResultsThe prevalence of active TrPs was 32.0%. Every TrPs-positive presented vasodilatation dependent on TrPs co-diagnosis (r = 0.72 p < 0.000) and pain recognition during DN (r = 0.4 p < 0.05). The size of vasodilatation in TrPs-positive subjects was: post-DN 12.3 ± 4.0% and post-observation 22.1 ± 6.1% (both p = 0.000) versus TrPs-negative: post-DN 0.4 ± 0.3% and post-observation 0.4 ± 0.2%. A significant temperature increase in the thigh and calf was confirmed for TrPs-positive subjects only (both p < 0.05). Post-DN and post-observation temperatures were as follows: average (thigh:1.2 ± 0.2°C; 1.4 ± 0.2°C, both p < 0.05 and calf: 0.4 ± 0.2°C; 0.4 ± 0.3°C, both p < 0.05) and maximum (thigh 1.4 ± 0.3°C 1.6 ± 0.3°C; both p < 0.05).ConclusionsThe presence of active TrPs within the gluteus minimus muscle among subacute sciatica subjects was confirmed. Every TrPs-positive sciatica patient presented DN related vasodilatation in the area of referred pain. The presence of vasodilatation suggests the involvement of sympathetic nerve activity in myofascial pain pathomechanism. Although the clinical meaning of TrPs in subacute sciatica patients is possible, further studies on a bigger group of patients are still required. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12614001060639. Registered 3 October 2014.

Reliability of MR-Based Volumetric 3-D Analysis of Pelvic Muscles among Subjects with Low Back with Leg Pain and Healthy Volunteers

Aim Lately, the diagnostic value of magnetic resonance imaging, Lasègue sign and classic neurological signs have been considered not accurate enough to distinguish the radicular from non-radicular low back with leg pain (LBLP) and a calculation of the symptomatic side muscle volume has been indicated as a probable valuable marker. However, only the multifidus muscle volume has been calculated so far. The main objective of the study was to verify whether LBLP subjects presented symptomatic side pelvic muscle atrophy compared to healthy volunteers. The second aim was to assess the inter-rater reliability of 3-D manual method for segmenting and measuring the volume of the gluteus maximus, gluteus medius, gluteus minimus and piriformis muscles in both LBLP patients and healthy subjects. Method Two independent raters analyzed MR images of LBLP and healthy subjects towards muscle volume of four pelvic muscles, i.e. the piriformis, gluteus minimus, gluteus medius and gluteus maximus. For both sides, the MR images of the muscles without adipose tissue infiltration were manually segmented in 3-D medical images. Results Symptomatic muscle atrophy was confirmed in only over 50% of LBLP subjects (gluteus maximus (p<0.001), gluteus minimus (p<0.01) and piriformis (p<0.05)). The ICC values indicated that the inter-rater reproducibility was greater than 0.90 for all measurements (LBLP and healthy subjects), except for the measurement of the right gluteus medius muscle in LBLP patients, which was equal to 0.848. Conclusion More than 50% of LBLP subjects presented symptomatic gluteus maximus, gluteus minimus and piriformis muscle atrophy. 3-D manual segmentation reliably measured muscle volume in all the measured pelvic muscles in both healthy and LBLP subjects. To answer the question of what kind of muscle atrophy is indicative of radicular or non-radicular pain further studies are required.

Dry Needling Related Short-Term Vasodilation in Chronic Sciatica under Infrared Thermovision

Vasomotor responses to dry needling (DN) of trigger points (TrPs) under infrared thermovision (IRT) camera control and TrPs coexistence in chronic sciatica patients have never been studied. Materials and Methods. Fifty consecutive chronic sciatica patients were enrolled in the study. DN under IRT control was performed for all patients regardless of gluteus minimus (GM) active TrPs examination. Then, the vasomotor response and its agreement with TrPs examination were evaluated. Results. The prevalence of GM active TrPs was 32%. DN provokes intensive vasodilatation for TrPs-positive patients only, with the localization dependent on referred pain during the procedure (r = 0.896;  P = 0.000) not the daily complaint. The increase of vasodilatation was, for example, for thigh, TrPs-positive +30.29% (P < 0.05) versus TrPs-negative +4.08%. Additionally, a significant skin temperature increase was observed for TrPs-positive only, for example, thigh +1.5 ± 1.3°C (maximum) and +1.2 ± 1.0°C (average) (both P < 0.05). Conclusion. GM active TrPs prevalence among chronic sciatica patients was around one in three. Every TrPs-positive subject presented with vasodilatation under IRT in the area of DN related referred pain. Although TrPs involvement in chronic sciatica patients is possible, further studies on a bigger group of patients are still required.

Intensive short-term vasodilation effect in the pain area of sciatica patients--case study.

BackgroundVaried and complicated etiology of low back pain radiating distally to the extremities is still causing disagreement and controversy around the issue of its diagnosis and treatment. Most clinicians believe that the source of that pain is generally radicular. While some of them postulate the clinical significance of the sacroiliac joint syndrome, others demonstrate that almost one in five people with back pain experience symptoms indicative of the neuropathic pain component. To date, neuropathic involvement has not been completely understood, and different mechanisms are thought to play an important role. It has been established that muscle pain (myofascial pain) e.g. active trigger points from the gluteus minimus, can mimic pain similar to sciatica, especially in the chronic stage. This paper describes patients presenting with radicular sciatica (case one and two) and sciatica-like symptoms (case three). For the first time, intensive short-term vasodilation in the pain area following needle infiltration of the gluteus minimus trigger point was recorded.Case presentationThree Caucasian, European women suffering from radicular sciatica (case one and two) and sciatica-like symptoms (case three) at the age of 57, 49 and 47 respectively underwent infrared camera observation during needle infiltration of the gluteus minimus trigger point. The patients were diagnosed by a neurologist; they underwent magnetic resonance imaging, electromyography, neurography and blood test analysis. Apart from that, the patients were diagnosed by a clinician specializing in myofascial pain diagnosis.ConclusionIn the examined cases, trigger points-related short-term vasodilation was recorded. Confirmation of these findings in a controlled, blinded study would indicate the existence of a link between the pain of sciatica patients (radicular or sciatica-like pain) and the activity of the autonomic nervous system. Further studies on a bigger group of patients are still needed.

Validation and Test-Retest Reliability of New Thermographic Technique Called Thermovision Technique of Dry Needling for Gluteus Minimus Trigger Points in Sciatica Subjects and TrPs-Negative Healthy Volunteers

The aim of this study was to assess the validity and test-retest reliability of Thermovision Technique of Dry Needling (TTDN) for the gluteus minimus muscle. TTDN is a new thermography approach used to support trigger points (TrPs) diagnostic criteria by presence of short-term vasomotor reactions occurring in the area where TrPs refer pain. Method. Thirty chronic sciatica patients (n=15 TrP-positive and n=15 TrPs-negative) and 15 healthy volunteers were evaluated by TTDN three times during two consecutive days based on TrPs of the gluteus minimus muscle confirmed additionally by referred pain presence. TTDN employs average temperature (T avr), maximum temperature (T max), low/high isothermal-area, and autonomic referred pain phenomenon (AURP) that reflects vasodilatation/vasoconstriction. Validity and test-retest reliability were assessed concurrently. Results. Two components of TTDN validity and reliability, T avr and AURP, had almost perfect agreement according to κ (e.g., thigh: 0.880 and 0.938; calf: 0.902 and 0.956, resp.). The sensitivity for T avr, T max, AURP, and high isothermal-area was 100% for everyone, but specificity of 100% was for T avr and AURP only. Conclusion. TTDN is a valid and reliable method for T avr and AURP measurement to support TrPs diagnostic criteria for the gluteus minimus muscle when digitally evoked referred pain pattern is present.

Skin Resistivity Value of Upper Trapezius Latent Trigger Points

Introduction. The skin resistivity (SkR) measurement is commonly recommended for acupoints measurement, but for trigger points (TrPs) only one study is available. The purpose of the study was to evaluate SkR for latent TrPs compared to non-TrPs and the surrounding tissue. Material and Methods. Forty-two healthy volunteers with unilateral latent upper trapezius TrPs (12 men, 30 women) aged 21–23 (mean age: 22.1 ± 0.6 y) participated in the study. Keithley electrometer 610B was used for measuring SkR (Ag/AgCl self-adhesive, disposable ground electrode: 30 mm diameter). SkR was measured for latent TrPs and compared to opposite non-TrPs sites and the surrounding tissue. Results. The SkR decrease of TrPs-positive sites as compared to TrPs-negative sites and the surrounding tissue was confirmed. However, no statistically significant difference in the SkR value occurred when all data were analyzed. The same was confirmed after gender division and for TrPs-positive subjects examined for referred pain and twitch response presence. Conclusion. SkR reactive changes at latent TrPs are possible but the results were not consistent with the previous study. Thus, caution in applying SkR to latent TrPs isolation is recommended and its clinical use should not be encouraged yet. Further studies, especially on active TrPs, are yet required.

Sacroiliac joint pain as an important element of psoriatic arthritis diagnosis.

Psoriatic arthritis (PsA) is a chronic inflammatory disease characterized by the coexistence of arthritis with psoriasis of the skin and nails. The sacroiliac joints were observed in 34-78% of patients with psoriatic arthritis. Due to such a high prevalence of SIJ dysfunction, understanding pathophysiology of pain and the associated pain pattern becomes a very important aspect of PsA diagnosis. As far as the etiology of SI joint dysfunction is concerned, it has not been disambiguated yet. Among the main causative factors, injuries and strains of the structures surrounding the joint are noted. Joint pathology usually manifests itself by pain occurring within the area of the joint. The causes of pain may be divided into two categories: intra-articular and extra-articular. Pain caused by the SI joint may be nociceptive or neural in nature, whereas the pain pattern characteristic of the joint correlates with its innervation and is consistent with S2 dorsal rami.

Tender Points and Trigger Points – Differences and Similarities

Abstract Objectives: There are two major types of non-inflammatory myalgia conditions, namely fibromyalgia syndrome [FMS] and myofascial pain syndrome [MPS]. In both cases, identifying the so-called tender points characteristic of FMS and trigger points characteristic of MPS is of key importance when making a diagnosis. Findings: The two syndromes are very similar and the above-mentioned points are difficult to distinguish during examination, which often leads to wrong diagnosis and, consequently, therapy failure. Additional difficulties are caused by the lack of coherence of nomenclature; in the literature the terms “tender point” and “trigger point” are used interchangeably. Moreover, some centers question the existence of FMS and MPS as separate pain entities. Conclusion: Although the differences in pathophysiology, the two syndromes are often mistaken. Further investigation and new assessment tools are needed to improve outcomes in both entities.