Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia

doi:10.1016/S0003-9993(96)90141-0

Archives of Physical Medicine and Rehabilitation

Volume 77, Issue 11, November 1996, Pages 1161-1166

https://doi.org/10.1016/S0003-9993(96)90141-0 Get rights and content

Abstract

Objective: To compare responses to trigger point (TrP) injection between patients having both myofascial pain syndrome (MPS) caused by active TrPs and fibromyalgia syndrome (FMS) and patients with MPS due to TrPs but without FMS.

Design: Prospective design blinded measurement, before-after trial.

Setting: A pain control medical clinic.

Patients: Group 1: MPS + FMS; Group 2: MPS only. All patients (9 in each group) had active TrPs in the upper trapezius muscle.

Intervention: Myofascial TrP injection with 0.5% xylocaine.

Main Outcome Measures: Subjective pain intensity (PI), pain threshold (PT), and range of motion (ROM) were assessed before, immediately after, and 2 weeks after TrP injection.

Results: In a comparison of preinjection measures to immediate postinjection measures, only ROM was significantly improved (p < .05) in Group 1 patients; all three parameters were significantly improved (p < .05) in the Group 2 patients who had only MPS. Two weeks after injection, both groups showed significant improvement (p < .05) in all three measured parameters as compared to preinjection measurements. In a comparison of the two groups, the immediate effectiveness of TrP injection was significantly iless (p < .05) in Group 1 than in Group 2 for all three parameters. Two weeks after injection, the degree of improvement in PT or ROM (but not PI) was not significantly different between two groups. Postinjection soreness (different from myofascial pain) was more severe, developed sooner, and lasted longer in Group 1 than in Group 2.

Conclusions: Trigger point injection is a valuable procedure for pain relief for patients in both group. Patients with FMS are likely to experience significant but delayed and attenuated pain relief following injection of their active TrPs compared to myofascial pain patients with similar TrPs but without FMS. Also, FMS patients are likely to experience significantly more postinjection soreness for a longer period of time.

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The trial-to-permanent implant conversion rate in the fibromyalgia cohort was 80.0%, which is concordant with the rates reported in the existing literature ranging between 63% and 89%.15–18 Although this comparative study investigates SCS outcomes specifically in the patient population with fibromyalgia, our findings contradict reports that patients with fibromyalgia who have undergone procedures such as trigger point injections have delayed and attenuated pain relief compared with patients without fibromyalgia.19 Even when patients with fibromyalgia are offered procedures for other pain indications, they may be poor responders, as demonstrated in a comparative study providing steroid injections for carpal tunnel syndrome in a fibromyalgia cohort vs control cohort.20
Fibromyalgia is a prevalent disorder manifesting with widespread musculoskeletal pain and central sensitization, as well as fatigue, sleep issues, psychologic distress, and poor quality of life. Patients with fibromyalgia also may be diagnosed with other painful conditions amenable to treatment with spinal cord stimulation (SCS), although it is unclear how these patients respond to SCS compared with patients without fibromyalgia.
We performed an 11-year, multicenter, retrospective matched cohort study comparing SCS-treated patients with fibromyalgia and those without fibromyalgia. The primary outcome was comparison in mean calculated percentage pain relief between cohorts at six months after SCS implantation. Secondary outcomes included comparison of patient satisfaction between six and 12 months after SCS implantation, and percentage of patients reporting opioid intake and neuropathic medication intake at six months and 12 months after SCS implantation. Adjusted regression analysis was performed to make comparisons while adjusting for age, sex, body mass index, Charlson comorbidity index, preoperative opioid intake, and preoperative neuropathic medication intake.
Of 90 patients with fibromyalgia who underwent SCS trial, 18 patients (20%) failed their SCS trial and did not proceed toward implantation. Sixty-eight patients with fibromyalgia were matched to 141 patients in the control cohort based on age, sex, Charlson comorbidity index, and the American Society of Anesthesiologists physical status score. At six months after SCS implantation, there was no statistical difference in calculated percentage change in pain intensity between the fibromyalgia cohort (46.6 ± 29.0) and the control cohort (50.9 ± 32.8; β, −18.4; 95% CI, −44.3 to 7.6; p = 0.157). At baseline, a greater percentage of patients in the fibromyalgia cohort reported preoperative opioid intake (51.5% vs 22.7%, p < 0.001) and preoperative neuropathic medication intake (67.6% vs 15.6%, p < 0.001). However, there was no difference between cohorts in the percentage of patients taking opioid or neuropathic medications at six months and 12 months after SCS implantation. Similarly, there was no difference between cohorts in the percentage of patients reporting satisfaction between six and 12 months.
Patients with fibromyalgia who received a diagnosis approved for treatment with SCS may expect similar post–SCS-implantation pain relief, overall satisfaction, and analgesic use rate to those of patients without fibromyalgia.
Post-needling soreness after myofascial trigger point dry needling: Current status and future research
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In the case of dry needling with syringe beveled needles, the postneedling soreness duration seems to be longer, with a reported mean duration of five days (Hong, 1994). Post-injection soreness lasted a mean of 13.7 days with a maximum intensity of 8.3 points on a 0–10 Likert subjective pain scale in fibromyalgia patients whose tender points were injected (Hong and Hsueh, 1996). These values were significantly higher than the postinjection soreness mean duration (1.2 days) and intensity (2.3 points) present in those with chronic neck pain who received lidocaine injections in active MTrPs.
Post-dry needling soreness is a common complication of myofascial trigger point (MTrP) dry needling treatment. The prevention, management and relevance of this complication remain uncertain. This paper examines the current state of knowledge and suggests directions for further studies in this area. MTrPs are hypersensitive nodules in skeletal muscles' taut bands, present in several pain conditions. Dry needling has been recommended for relieving MTrP pain. MTrP dry needling procedures have shown to be associated with post-needling soreness, which is thought to be a consequence of the neuromuscular damage, and hemorrhagic and inflammatory reaction generated by the needle. Postneedling soreness is a very frequent effect after deep dry needling, usually lasting less than 72 h. It may not be especially distressing for most patients. However, patients presenting with higher levels of post-needling soreness, not perceiving dry needling effectiveness in the first session, or not having high myofascial pain intensity before treatment, could be the most likely to find post-needling soreness more distressing, functionally limiting and to abandon treatment. Future research should assess the clinical relevance of post-needling soreness. Post-needling soreness should be considered when investigating dry needling effectiveness since it could overlie the original myofascial pain and influence the patients’ pain ratings.
Ischemic Compression After Dry Needling of a Latent Myofascial Trigger Point Reduces Postneedling Soreness Intensity and Duration
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To investigate the effect of ischemic compression (IC) versus placebo and control on reducing postneedling soreness of 1 latent myofascial trigger point and on improving cervical range of motion (CROM) in asymptomatic subjects.
A randomized, double-blind, placebo-controlled trial with 72-hour follow-up.
A university community.
Asymptomatic volunteers (N = 90: 40 men and 50 women) aged 18 to 39 years (mean ± standard deviation [SD]: 22 ± 3 years).
All subjects received a dry needling application over the upper trapezius muscle. Participants were then randomly divided into 3 groups: a treatment group who received IC over the needled trapezius muscle, a placebo group who received sham IC, and a control group who did not receive any treatment after needling.
Visual analog scale (VAS; during needling, at posttreatment and 6, 12, 24, 48, and 72 hours) and CROM (at preneedling, postneedling, and 24 and 72 hours).
Subjects in the IC group showed significantly lower postneedling soreness than the placebo and the control group subjects immediately after treatment (mean ± standard deviation [SD]: IC, 20.1 ± 4.8; placebo, 36.7 ± 4.8; control, 34.8 ± 3.6) and at 48 hours (mean ± SD: IC, 0.6 ± 1; placebo, 4.8 ± 1; control, 3.8 ± 0.7). In addition, subjects in the dry needling+IC group showed significantly lower postneedling soreness duration (P = .026). All subjects significantly improved CROM in contralateral lateroflexion and both homolateral and contralateral rotations, but only the improvements found in the IC group reached the minimal detectable change.
IC can potentially be added immediately after dry needling of myofascial trigger point in the upper trapezius muscle because it has the effect of reducing postneedling soreness intensity and duration. The combination of dry needling and IC seems to improve CROM in homolateral and contralateral cervical rotation movements.
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Some authors consider it to be beneficial (Castro et al., 2004; Giamberardino, Affaitati, Fabrizio, & Costantini, 2011; Malo & Perez, 1998), while others claim that it has no more effect than placebo (Janzen & Scudds, 1997). According to Hong and Hsueh (1996), infiltration reduces the number of tender points but does not reduce the rest of the pain. Tricyclic antidepressants, cyclobenzaprine, and infiltrations with local anesthetics have been shown to be effective pharmacological agents if used in conjunction with an appropriate psychological and rehabilitation plan (Malo & Perez, 1998).
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Although acute pain is a physiological response warning the human body of possible harm, chronic pain can be a pathological state associated with various diseases or a disease in itself. In the United States alone, around one-third of the population has experienced a chronic pain condition and annual cost to the society is in the range of 500–600 billion dollars.¹ It should be noted that if at all this is a very modest estimate, it surpasses the costs associated with cancer, heart disease, and diabetes combined.¹ Unfortunately, despite these humongous costs, the treatment of chronic pain is inadequate.¹ Chronic pain affects individuals in a variety of forms, and below we highlight some of the most common chronic pain conditions seen in a pain clinic. Most of these disorders are difficult to treat and typically require multimodal therapy including pharmacotherapy, behavioral modification, and targeted interventions. We have summarized the scope of each disorder, clinical features, proposed mechanisms, and current therapies for them (Table 1).

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^☆: Supported in part by the Roosevelt Warm Springs Foundation.

^☆☆: No commercial party having a direct or indirect interest in the subject matter of this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

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ArticleDifference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia☆,☆☆

Abstract

Phys Med Rehabil Clin North Am

Pain

Arch Phys Med Rehabil

Pain

Pain

The clinical assessment of myofascial pain

Trigger points

Myofascial pain syndrome due to trigger points

Myofascial pain syndrome

Comparison of local twitch responses elicited by palpation and needling of myofascial trigger points

J Musculoskel Pain

The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease

J Rheumatol

Intertester reliability of judgements of the pressure of trigger points in patients with low back pain

Arch Phys Med Rehabil

Identification of myofascial trigger points: Inter-rater agreement and effect of training

J Musculoskel Pain

The fibrositis/fibromyalgia syndrome: current issues and prospective

Am J Med

Article
Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia☆,☆☆