Silvia Ambite-Quesada

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.

Bilateral, wide-spread, mechanical pain sensitivity in children with frequent episodic tension-type headache suggesting impairment in central nociceptive processing.

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 (rs = −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.

Specific Mechanical Pain Hypersensitivity Over Peripheral Nerve Trunks in Women With Either Unilateral Epicondylalgia or Carpal Tunnel Syndrome

STUDY DESIGN Case-control study with blinded examiner. OBJECTIVE To investigate if pressure pain sensitivity is related to specific nerve trunks in the upper extremity of patients with either unilateral lateral epicondylalgia (LE) or carpal tunnel syndrome (CTS). BACKGROUND In the clinical setting, patients with LE tend to exhibit radial nerve trunk tenderness, whereas patients with CTS exhibit median nerve tenderness. No studies have investigated if specific nerve pressure pain hypersensitivity exists in patients with either LE or CTS. METHODS Sixteen women with unilateral LE (mean±SD age, 43±7 years), 17 women with unilateral CTS (43±6 years), and 17 healthy women (43±6 years) were included in this study. Pressure pain thresholds (PPT) were bilaterally assessed over the median, ulnar, and radial nerve trunks, as well as over the C5-6 zygapophyseal joints, by an examiner blinded to the subjectsí condition. A mixed-model analysis of variance was used to evaluate differences in PPT among groups (LE, CTS, or controls) and between sides (affected/nonaffected or dominant/nondominant). RESULTS The individuals in both the LE and CTS groups demonstrated lower PPT bilaterally over the median (group, P<.001; side, P=.437), radial (group, P<.001; side, P=.556), and ulnar (group, P<.001; side, P=.938) nerve trunks as compared to controls. Additionally, radial (P<.001) and ulnar (P=.005) nerves were more sensitive bilaterally in patients with LE than in patients with CTS. The median nerve was more sensitive bilaterally in patients with CTS than patients with LE (P=.002). Lower PPT over the cervical spine (group, P<.001; side, P=.233) were found bilaterally in both the LE and CTS groups. Further, patients with CTS exhibited lower cervical PPT than patients with LE (P<.001). PPT was negatively correlated with both pain intensity and duration of symptoms in both the LE and CTS groups (P<.001). CONCLUSIONS Bilateral mechanical nerve pain hypersensitivity is related to specific and particular nerve trunks in women with either unilateral LE or CTS. Our results suggest the presence of central and peripheral sensitization mechanisms in individuals with either LE or CTS.

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.

Influence of catechol-o-methyltransferase genotype (Val158Met) on endocrine, sympathetic nervous and mucosal immune systems in breast cancer survivors

Stress can play an important role in development of cancer-related fatigue (CRF) by activating the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic nervous system (SNS), and altering the immune system. This study examined the influence of catechol-O-methyltransferase (COMT) Val158Met genotypes on salivary markers of HPA axis (cortisol), SNS (α-amylase) and immune (IgA) systems, as well as on CRF in breast cancer survivors (BCS). One-hundred BCS participated. After amplifying Val158Met COMT polymorphisms by polymerase chain reaction, three COMT genotypes were considered: Val/Val, Val/Met, Met/Met. Salivary cortisol, α-amylase activity, salivary flow rate, and IgA concentration were collected from non-stimulated saliva. CRF was assessed with the fatigue subscale of the Profile of Mood State (POMS) questionnaire. We found that BCS carrying Met/Met genotype reported higher cortisol concentration, α-amylase activity and greater CRF than those with Val/Met (P < 0.05) and Val/Val (P < 0.001) genotypes. No differences in salivary flow rate or IgA concentration (P > 0.20) were found. The results suggest that BCS carrying Met/Met genotype exhibit greater dysfunction of the HPA axis and SNS system associated with severe CRF. This study is important because it strives to understand biological factors that predispose some BCS to higher levels of CRF.

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.

Generalized Mechanical Nerve Pain Hypersensitivity in Children With Episodic Tension-type Headache

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 patients 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 (rs = −0.4, P < .05) and radial (rs = −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.

Identification of Subgroups of Women with Carpal Tunnel Syndrome with Central Sensitization

OBJECTIVE Identification of subjects with different sensitization mechanisms can help to identify better therapeutic strategies for carpal tunnel syndrome (CTS). The aim of the current study was to identify subgroups of women with CTS with different levels of sensitization. METHODS A total of 223 women with CTS were recruited. Self-reported variables included pain intensity, function, disability, and depression. Pressure pain thresholds (PPT) were assessed bilaterally over median, ulnar, and radial nerves, C5-C6 joint, carpal tunnel, and tibialis anterior to assess widespread pressure pain hyperalgesia. Heat (HPT) and cold (CPT) pain thresholds were also bilaterally assessed over the carpal tunnel and the thenar eminence to determine thermal pain hyperalgesia. Pinch grip force between the thumb and the remaining fingers was calculated to determine motor assessment. Subgroups were determined according to the status on a previous clinical prediction rule: PPT over the affected C5-C6 joint < 137 kPa, HPT on affected carpal tunnel <39.6ºC, and general health >66 points. RESULTS The ANOVA showed that women within group 1 (positive rule, n = 60) exhibited bilateral widespread pressure hyperalgesia (P < 0.001) and bilateral thermal thresholds (P < 0.001) than those within group 2 (negative rule, n = 162). Women in group 1 also exhibited higher depression than those in group 2 (P = 0.023). No differences in self-reported variables were observed. CONCLUSION This study showed that a clinical prediction rule originally developed for identifying women with CTS who are likely to respond favorably to manual physical therapy was able to identify women exhibiting higher widespread pressure hyper-sensitivity and thermal hyperalgesia. This subgroup of women with CTS exhibiting higher sensitization may need specific therapeutic programs.

Catechol-O-Methyltransferase Val158Met Polymorphism (rs4680) Is Associated With Pain in Multiple Sclerosis

UNLABELLED Alterations in the rs4680 Val158Met polymorphism are associated with the presence of pain. No study has investigated the role of Val158Met polymorphism in the susceptibility to exhibit pain in multiple sclerosis (MS). Our aim was to investigate the relationship between Val158Met polymorphism (rs4680) and the presence of pain in MS. One hundred eight (n = 108) patients (mean age: 44 ± 8 years) with a definitive diagnosis of MS and 108 matched controls participated. Fifty-eight patients (54%) had pain and 50 (46%) did not report pain. After amplifying Val158Met polymorphisms by polymerase chain reactions, rs4680 genotype frequencies and allele distributions were calculated. We classified individuals according to their Val158Met polymorphism: Val/Val, Val/Met, and Met/Met. The results showed that distribution of rs4680 Val158Met genotypes was not significantly different between individuals with MS in general and healthy people (χ2 = 2.212, P = .331). When we differentiate MS patients with pain and those without pain, the prevalence of Val158Met genotypes was significantly different (χ2 = 9,610, P = .046): Patients experiencing pain exhibited higher prevalence of Met/Met genotype than those without pain and healthy controls. Current results suggest that the Met allele of Val158Met polymorphism could be a potential risk factor for the development of pain in MS but not for the predisposition of MS itself. PERSPECTIVE This study suggests that the Val158Met polymorphism is associated with the presence of pain in MS, but it is not a risk factor for MS itself because the presence of the Met/Met genotype was more prevalent in those patients with pain. This study provides further evidence of potential genetic factors that predispose patients with MS to develop pain.

Direct and Indirect Effects of Function in Associated Variables Such as Depression and Severity on Pain Intensity in Women with Carpal Tunnel Syndrome

OBJECTIVE To determine the direct and indirect effects of function on clinical variables such as age, pain intensity, years of the disease, severity of symptoms, and depression in women with electrodiagnostic and clinical diagnosis of carpal tunnel syndrome (CTS). DESIGN A cross-sectional study. SETTING Patients from an urban hospital referred to a university clinic. METHODS Two hundred and forty-four (n = 224) women with CTS were included. Demographic and clinical data, duration of symptoms, function, symptoms severity of the symptoms, pain intensity, and depression were self-reported collected. Correlation and path analysis with maximum likelihood estimation were conducted to assess the direct and indirect effect of hand function on pain, age, years with the disease, symptoms severity, and depression. RESULTS Significant positive correlations between function and pain intensity, years with pain and symptoms severity were observed. The path analysis found direct effects from depression, symptoms severity, and years with pain to function (all, P < 0.01). Paths between function and depression on pain intensity (both, P < 0.01) were also observed. The amount of function explained by all predictors was 22%. The indirect effects in the path analysis revealed that function exerted an indirect effect from depression to pain intensity (B = 0.18; P < 0.01), and from symptoms severity to the intensity of pain (B = 0.10; P < 0.01). Overall, the amount of current pain intensity explained by all predictors in the model was R(2)  = 0.22. CONCLUSIONS Our study demonstrated that function mediates the relationship between depression and symptoms severity with pain intensity in women with CTS. Future longitudinal studies will help to determine the clinical implications of these findings.