|Labat JJ, Guerineau M, Delavierre D et al. 2010. [Symptomatic approach to musculoskeletal dysfunction and chronic pelvic and perineal pain.] Prog Urol 20(12):982-989. [French] "Musculoskeletal pain is certainly underestimated in the management of chronic pelvic and perineal pain."
Labat JJ, Ribert R, Delavierre D et al. 2010. [Symptomatic approach to chronic neuropathic somatic pelvic and perineal pain] Prog Urol 20(12):973-981. Chronic pelvic and perineal pain must include assessment and treatment of entrapped nerves and trigger points in scars, facet joint pain and multiple other factors. [French]
Lachaine J, Beauchemin C, Landry PA. 2010. Clinical and economic
characteristics of patients with fibromyalgia syndrome. Clin
J Pain. 26(4):284-290. “Results of this analysis of the RAMQ
(Quebec provincial health plans) database illustrate the high
prevalence of comorbidities among patients with a diagnosis of
FMS and strongly indicate that the economic burden of FMS is
substantial.” [It is vital to discover the initiating cause of
the central sensitization of FM, and even more, the
comorbidities and other factors that are maintaining it. DJS]
ML, Tawfik VL, DeLeo JA. 2005. The organizational and
activational effects of sex hormones on tactile and thermal
hypersensitivity following lumbar nerve root injury in male an
female rates. Pain 114(1-2):71-80. “Manipulation
of gonadal hormones may be a potential source for novel
therapies for chronic pain in women.”
A. L., L. B. Cabrales, R. M. Larramendi. 2002. Bioelectrical
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Lago-Rizzardi CD, de Siqueira JT, de Siqueira SR. 2013. Spirituality of chronic orofacial pain patients: Case-control study. J Relig Health. [Aug 29 Epub ahead of print]. This study was from the Neurology Department, University of Sao Paulo Brazil Medical School. "The objective of this study was to investigate spirituality and blood parameters associated with stress in patients with facial musculoskeletal pain. Twenty-four women with chronic facial musculoskeletal pain (CFMP) and 24 healthy women were evaluated with a protocol for orofacial characteristics, research diagnostic criteria for temporomandibular disorders and the Spiritual Perspective Scale. Blood samples were collected to analyze blood count, cortisol, ACTH, C3, C4, thyroid hormones, total immunoglobulin, C-reactive protein and rheumatoid factor. The study group was more spiritualized than control group. Individuals with a high score of spirituality had less myofascial pain, less bruxism and fewer complaints. They also had lower levels of ACTH and IgE. Spirituality was higher in the study group and can be considered an important tool for coping with CFMP".
Lahita, R. G.
1998. Collagen disease: the enemy within. Int J
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Lai, H. and
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Lai HH, Gardner V, Ness TJ et al. 2013. Segmental Hyperalgesia to Mechanical Stimulus in Interstitial Cystitis/Bladder Pain Syndrome - Evidence of Central Sensitization. J Urol. [Dec 5 Epub ahead of print.] "Female subjects with IC/BPS showed segmental hyperalgesia to mechanical pressure stimulation in the suprapubic area (T10-T12). This segmental hyperalgesia may be explained in part by spinal central sensitization."
Lakhan SE, Avramut M, Tepper SJ. 2012. Structural and Functional Neuroimaging in Migraine: Insights from 3 Decades of Research. Headache. [Oct 23 Epub ahead of print]. "Modern imaging methods provide unprecedented insights into brain structure, perfusion, metabolism, and neurochemistry, both during and between migraine attacks. Neuroimaging investigations conducted in recent decades bring us closer to uncovering migraine as a multifaceted, primarily central nervous system disorder. Three main categories of structural and functional brain changes are described in this review, corresponding to the migrainous aura, ictal headache, and interictal states. These changes greatly advance our understanding of multiple pathophysiologic underpinnings of migraine, from central "migraine generating" loci, to cortical spreading depression, intimate mechanisms underlying activation of neuronal pain pathways in vulnerable patients, central sensitization, and chronification. Structural imaging begins to explain the complex connections between migraine and cerebral vascular events, white matter lesions, grey matter density alterations, iron deposition, and microstructural brain damage. Selected structural and functional alterations of brain structures, as identified with imaging methods, may represent the foundation of new diagnostic strategies and serve as markers of therapeutic efficacy."
Lakomek HJ, Lakomek M, Bosquet-Nahrwold
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“The importance of fibromyalgia has been recognized within the
German health system by creating the new ICD code M79.70 and by
assigning fibromyalgia its own rheumatologic DRG (I79Z).
Lamotte M, Maugars Y, Le Lay K. 2010. Health economic evaluation of outpatient management of fibromyalgia patients and the costs avoided by diagnosing fibromyalgia in France. Clin Exp Rheumatol. 28(6 Suppl 63):S64-70. "…in France, early diagnosis of fibromyalgia leads to a decrease in resource use and health care costs."
Lan C, Chen SY, Lai JS et al. 2013. Tai chi chuan in medicine and health promotion. Evid Based Complement Alternat Med. 2013:502131. "Tai chi chuan (Tai Chi) is a Chinese traditional mind-body exercise, and recently, it becomes popular worldwide. During the practice of Tai Chi, deep diaphragmatic breathing is integrated into body motions to achieve a harmonious balance between body and mind and to facilitate the flow of internal energy (Qi). Participants can choose to perform a complete set of Tai Chi or selected movements according to their needs. Previous research substantiates that Tai Chi has significant benefits to health promotion, and regularly practicing Tai Chi improves aerobic capacity, muscular strength, balance, health-related quality of life, and psychological well-being. Recent studies also prove that Tai Chi is safe and effective for patients with neurological diseases (e.g., stroke, Parkinson's disease, traumatic brain injury, multiple sclerosis, cognitive dysfunction), rheumatological disease (e.g., rheumatoid arthritis, ankylosing spondylitis, and fibromyalgia), orthopedic diseases (e.g., osteoarthritis, osteoporosis, low-back pain, and musculoskeletal disorder), cardiovascular diseases (e.g., acute myocardial infarction, coronary artery bypass grafting surgery, and heart failure), chronic obstructive pulmonary diseases, and breast cancers. Tai Chi is an aerobic exercise with mild-to-moderate intensity and is appropriate for implementation in the community. This paper reviews the existing literature on Tai Chi and introduces its health-promotion effect and the potential clinical applications."
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intensity aerobic exercise.
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tolerability of botulinum toxin serotypes A and B in the
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Myofascial pain patients treated with BTX-A “...reported
significantly greater reductions in pain for longer
durations...” than BTX-B, and there were no “severe
systemic adverse effects,” which was not the case with BTX-B.
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Lange G, Janal MN, Maniker A et al. 2011. Safety and Efficacy of Vagus Nerve Stimulation in Fibromyalgia: A Phase I/II Proof of Concept Trial. Pain Med. [Aug 3 Epub ahead of print]. "Side effects and tolerability were similar to those found in disorders currently treated with VNS (vagus nerve stimulation.) Preliminary outcome measures suggested that VNS may be a useful adjunct treatment for FM patients resistant to conventional therapeutic management, but further research is required to better understand its actual role in the treatment of FM."
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[German] “Comparison of the groups shows significantly
lower means for the fibromyalgia patients with depressive
symptoms concerning ‘perceived self-competence’, ‘cognitive
restructuring’, and ‘countertraded activity’. The same
results can be observed for ‘self-efficacy’. Analysis of
the motivation for therapy in the ‘carefreeness’ scale shows
significantly higher means in the fibromyalgia patients with
depressive symptoms. In the ‘maintenance’ scale, however,
lower means are observed in this patient group. As
fibromyalgia patients with depressive symptoms show greater
strain on account of their psychosomatic symptoms, depressive
symptoms should be dealt with during treatment.” [No
consideration was made for the effects of living with an
invisible illness that had little understanding and little
support among care providers and companions alike. It is
very difficult to be “carefree” when you are living with a
bewildering number of symptoms, often caused by a multitude of
co-existing conditions, many of which are unrecognized by care
providers. This situation lends itself toward fostering an
attitude of hopelessness and helplessness, underscored by often
enhanced by inadequately treated pain. Perhaps when care
providers become more educated, patients will as well, and
become less depressed as their symptoms are more adequately
Langevin HM. 2006. Connective tissue: a body-wide
signaling network? Med Hypotheses. 66(6):1074-1077.
“Unspecialized ‘loose’ connective tissue forms an anatomical
network throughout the body. This paper presents the
hypothesis that, in addition, connective tissue functions as a
body-wide mechanosensitive signaling network.”
“Demonstrating the existence of a connective signaling network
therefore may profoundly influence our understanding of health
and disease.” [This concept is increasingly important due
to the finding of trigger points in so many types of tissue, and
that at least MTPs have part in central sensitization. DJS]
Langevin HM, Nedergaard M, Howe AK. 2013. Cellular control of connective tissue matrix tension. J Cell Biochem. Aug;114(8):1714-9. "The biomechanical behavior of connective tissue in response to stretching is generally attributed to the molecular composition and organization of its extracellular matrix. It also is becoming apparent that fibroblasts play an active role in regulating connective tissue tension. In response to static stretching of the tissue, fibroblasts expand within minutes by actively remodeling their cytoskeleton. This dynamic change in fibroblast shape contributes to the drop in tissue tension that occurs during viscoelastic relaxation. We propose that this response of fibroblasts plays a role in regulating extracellular fluid flow into the tissue, and protects against swelling when the matrix is stretched. This article reviews the evidence supporting possible mechanisms underlying this response including autocrine purinergic signaling. We also discuss fibroblast regulation of connective tissue tension with respect to lymphatic flow, immune function, and cancer."
Langevin HM, Sherman KJ. 2007. Pathophysiological model
for chronic low back pain integrating connective tissue and
nervous system mechanisms. Med Hypotheses.
68(1):74-80. [Most chronic low back pain includes MTPs,
and the MTPs can cause central sensitization. Since pain
at the end of range of motion is due to MTPs and the MTPs can
cause central sensitization contributing to chronic pain (see
Niddam et al 2008), the myofascial component must be diagnosed
and treated for the therapies mentioned in this article to be
Langford CF, Udvari Nagy S, Ghoniem GM.
2007. Levator ani trigger point injections: an
underutilized treatment for chronic pelvic pain.
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non-surgical office-based therapy such as trigger point
injections can be effective in selected patients.”
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E. Buchalter and V. Giambanco. 1999. St. John’s
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Lara NA Jr, Teixeira MJ, Fonoff ET. 2011. Long Term Intrathecal Infusion of Opiates for Treatment of Failed Back Surgery Syndrome. Acta Neurochir Suppl. 108:41-47. "Failed Back Surgery Syndrome (FBSS) is a multidimensional painful condition and its treatment remains a challenge for the surgeons. Prolonged intrathecal infusion of opiates for treatment of noncancer pain also remains a controversial issue. (In this study it) was concluded that intrathecal infusion of morphine is a useful and safe tool for long-term treatment of chronic nonmalignant pain."["Failed back syndrome" is a description, not a diagnosis, and is often due to myofascial TrPs. One must always start with the least invasive therapies. DJS]
Lark SD, McCarthy PW.
2007. Cervical range of motion and proprioception
in rugby players versus non-rugby players. J
Sports Sci. 25(8):887-894. “The active
cervical range of motion of rugby forwards is similar to
that of whiplash patients, suggesting that participation
in rugby can have an effect on neck range of motion that
is equivalent to chronic disability. Reduced
active cervical range of motion could also increase the
likelihood of injury and exacerbate age-related neck
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and R. Holm. 2000. [Prolonged neck pain following
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Larson AA, Pardo JV, Pasley JD. 2013. Review of Overlap between Thermoregulation and Pain Modulation in Fibromyalgia. Clin J Pain. [Jul 24 Epub ahead of print]. "Fibromyalgia (FM) syndrome is characterized by widespread pain that is exacerbated by cold and stress but relieved by warmth. We review the points along thermal and pain pathways where temperature may influence pain. We also present evidence addressing the possibility that brown adipose tissue activity is linked to the pain of FM given that cold initiates thermogenesis in brown adipose tissue through adrenergic activity, whereas warmth suspends thermogenesis. Although females have a higher incidence of FM and more resting thermogenesis, they are less able to recruit brown adipose tissue in response to chronic stress than males. In addition, conditions that are frequently comorbid with FM compromise brown adipose activity making it less responsive to sympathetic stimulation. This results in lower body temperatures, lower metabolic rates, and lower circulating cortisol/corticosterone in response to stress-characteristics of FM. In the periphery, sympathetic nerves to brown adipose also project to surrounding tissues, including tender points characterizing FM. As a result, the musculoskeletal hyperalgesia associated with conditions such as FM may result from referred pain in the adjacent muscle and skin."
B., Bjork, J., Henriksson, K.J., Gerdle, B., Lindman, R. 2000.
The prevalence of cytochrome oxidase negative and
super-positive fibers and ragged red fibers in the trapezius
muscle of female cleaners with and without myalgia and/or
female healthy controls. Peripheral pain input from injuries,
inflammation, or chronic work-related myalgia are probable
sources of persistent nociceptive impulses could lead to a
central sensitization. Furthermore, once central
sensitization develops, peripheral pain generators, such as
myofascial trigger points, may lead to perpetuation and
aggravation of central sensitization.
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La Rubia M, Rus A, Molina F et al. 2013. Is fibromyalgia-related oxidative stress implicated in the decline of physical and mental health status? Clin Exp Rheumatol. 31(6 Suppl 79):121-127. "These findings reveal an imbalance between oxidants and antioxidants in FM patients. The lower antioxidant enzyme activities may lead to oxidative stress through the oxidation of DNA and proteins, which may affect the health status of FM patients."
Laske C, Stransky E, Eschweiler GW et al.
2006. Increased BDNF serum concentration in fibromyalgia
with or without depression or antidepressants. J
Psychiatr Res. [Apr 3 Epub ahead of print]
“Fibromyalgia (FM) is still often viewed as a psychosomatic
disorder. However, the increased pain sensitivity to
stimuli in FM patients is not an ‘imagined’ histrionic
phenomena. Pain, which is consistently felt in the
musculature, is related to specific abnormalities in the CNS
pain matrix. Brain-derived neurotrophic factor (BDNF) is
an endogenous protein involved in neuronal survival and synaptic
plasticity of the central and peripheral nervous system (CNS and
PNS). Several lines of evidence converged to indicate that
BDNF also participates in structural and functional plasticity
of nociceptive pathways in the CNS and within the dorsal root
ganglia and spinal cord. In the latter, release of BDNF
appears to modulate or even mediate nociceptive sensory inputs
and pain hypersensitivity. We were interested if BDNF
serum concentration may be altered in FM.” “The results from
our study indicate that BDNF may be involved in the
pathophysiology of pain in FM. Nevertheless, how BDNF
increases susceptibility to pain is still not known.”
Latina R, Sansoni J, D'Angelo D et al. 2013. [Etiology and prevalence of chronic pain in adults: a Narrative Review.] Prof Inferm. 66(3):151-158. [Article in Italian] "The chronic nonmalignant pain is an underestimated epidemiologic health problem. It is a disease in its own right. It is one of the major reasons because patients use health service. The magnitude of chronic pain is in terms of human suffering and costs to society. The aim of this review is to identify the diagnosis and the prevalence of nonmalignant chronic pain in the adults….Excluding topics of headache, pain for pediatric and geriatric groups, cancer pain and disease-specific items. … We have obtained 7 articles. These epidemiological studies conducted in different part of the world, reported prevalence rates of chronic pain ranging from 16-53%. They show a high heterogeneity of results concerning diagnosis and methods. Although limited the number of articles, show the high complexity of the phenomenon."
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action of intravenous lidocaine is a reflection of its
multifactorial action. It has been suggested that its
central sensitization is secondary to a peripheral anti-hyperalgic
action on somatic pain and central on neuropathic pain, which
result in the blockade of central hyperexcitability. The
intravenous dose should not exceed the toxic plasma
concentration of 5 microg mL(-1); doses smaller than 5 mg
kg(-1), administered slowly (30 minutes), under monitoring, are
Lautenbacher S. 2012. Experimental approaches in the study of pain in the elderly. Pain Med. 13 Suppl 2:S44-50. "The present review summarizes experimental data on age-related changes in pain processing. These data suggest an increase in pain threshold and a decrease in tolerance threshold, which both are dependent on the physical nature of the stressor, as well as a developing deficiency in endogenous pain inhibition, which might be paralleled by an enhanced disposition to central sensitization (stronger temporal summation). These findings are arranged in a model that allows for explaining the two seemingly divergent perspectives: age both dulls the pain sense and increases the prevalence of pain complaints. This model is based on the assumption that both excitatory and inhibitory processes are dampened with age but that the later processes age at a faster rate, leading to increasingly unbalanced pain excitation."
Lautenbacher S, Kunz M,
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thresholds, temporal summation and spatial summation of
heat and pressure pain. “...somatosensory
thresholds for non-noxious stimuli increase with age
whereas pressure pain thresholds decrease and heat pain
thresholds show no age-related changes.”
Lautenbacher S, Rollman
GB, McCain GA. 1994. Multi-method assessment of
experimental and clinical pain in patients with
fibromyalgia. Pain 59(1):45-53. There
is increased pain responsiveness for any noxious stimuli
in FM patients, including cold, heat, and electronic
stimulation, although the latter was noted in the tender
Lavand’homme P, De Kock M. 2006.
The use of intraoperative epidural or spinal analgesia
modulates postoperative hyperalgesia and reduces residual
pain after major abdominal surgery. Acta
Anaesthesiol Belg. 57(4):373-379. Blocking
nociceptive stimuli with multimodal analgesia on the
surgical incision site may prevent or at least minimize
central sensitization after abdominal procedures.
Lavand’homme P. 2006.
Perioperative pain. Curr Opin Anaesthesiol.
19(5):556-561. “Effective perioperative block of nociceptive
inputs from the wound as well as use of antihyperalgesic and
analgesic drugs in combination seem the best way to control
postoperative pain and specifically to prevent central
Lavaque E, Sierra A, Azcoitia I et al.
2005. Steroidogenic acute regulatory protein in the brain.
Neuroscience [Dec. 6 Epub ahead of print] “The nervous
system synthesizes steroids that regulate the development and
function of neurons and glia, and have neuroprotective
properties. The first step in steroidogenesis involves the
delivery of free cholesterol to the inner mitochondrial membrane
where it can be converted into pregnenolone by the enzyme
cytochrome P450side chain cleavage. The peripheral-type
benzodiazepine receptor and the steroidogenic acute regulatory
protein are involved in this process and appear to function in a
coordinated manner.” “Steroidogenic acute regulatory protein is
regulated in the nervous system by different physiological and
pathological conditions and may play an important role during
brain development, aging and after injury.”
Lavelle ED, Lavelle W, Smith HS. 2007. Myofascial
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Lavergne MR, Cole DC,
Kerr K et al. 2010. Functional impairment in chronic fatigue
syndrome, fibromyalgia, and multiple chemical sensitivity.
Can Fam Physician. 56(2):e57-65. “The patient
population was predominantly female (86.7%), with a mean age
of 44.6 years. Seventy-eight patients had discrete diagnoses
of 1 of MCS, CFS, or FM, while the remainder had 2 or 3
overlapping diagnoses. Most (68.8%) had stopped work, and on
average this had occurred 3 years after symptom onset. On
every Short Form-36 subscale, patients had markedly lower
functional scores than population average values, more so
when they had 2 or 3 of these diagnoses. Having FM, younger
age at onset, and lower socioeconomic status were most
consistently associated with poor function. CONCLUSION:
Patients seen at the EHC demonstrated marked functional
impairment, consistent with their reported difficulties
working and caring for their homes and families during what
should be their peak productive years. Early comprehensive
assessment, medical management, and social and financial
support might avoid the deterioration of function associated
with prolonged illness. Education and information resources
are required for health care professionals and the public,
along with further etiologic and prognostic research.” [The
loss to society, as well as to the patients and their
families, is tremendous. More care must be taken to prevent
these conditions and avoid these perpetuating factors.
Beginning symptoms must be pounced upon as a cat on a mouse,
and care must be taken to avoid worsening of the conditions.
Lavin, R. A.,
M. Pappagallo and K. V. Kuhlemeier. 1997. Cervical pain:
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Lawrence RC, Felson DT, Helmick CG et al. 2007. Estimates
of the prevalence of arthritis and other rheumatic conditions in
the United States: Part II. Arthritis Rheum.
58(1):26-35. “Estimates for many specific rheumatic
conditions rely on a few, small studies of uncertain
generalizability to the US population. This report
provides the best available prevalence estimates for the US, but
for most specific conditions more studies generalizable to the
US or addressing understudied populations are needed.”
[This study estimated that among US adults, 5 million have FM.
They also mentioned 59 million with low back pain and 30.1
million with neck pain, but did not specify MTPs. Since
most of the conditions they counted often do have a myofascial
component, the numbers of people with MTPs is staggering. So is
the fact that they ignored this in this NIH study. DJS]
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Does over-the-counter nicotine replacement therapy improve
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Lawson GE, Hung LY, Ko GD et al. 2011. A case of pseudo-angina pectoris from a pectoralis minor trigger point caused by cross-country skiing. J Chiropr Med. 10(3):173-178. "This case demonstrates the importance of differential diagnosis and mechanism of injury in regard to chest pain and that chiropractic management can be successful when addressing patients with chest wall pain of musculoskeletal origin."
Le H, Tfelt-Hansen P, Russell MB et al. 2010. Co-morbidity of migraine with somatic disease in a large population-based study. Cephalalgia. [Jun 2 Epub ahead of print]. "The aim of this study was to determine sex specific co-morbidity of migraine and its subtypes migraine without aura (MO) and migraine with aura (MA) with a number of common somatic diseases..... Co-morbid diseases included previously documented diseases: asthma, epilepsy and stroke as well as new conditions: kidney stone, psoriasis, rheumatoid arthritis and fibromyalgia. MA had more co-morbidities than MO and females more than males.... Migraine occurs in 20-30% of several medical conditions. It should be diagnosed and treated along with the primary disease."
Leach, M. W.,
D. W. Frank, M. R. Berardi, E. W. Evans, R. C. Johnson, D. G.
Schuessler and E. Radwanski. 1999. Renal changes
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2000. Obesity: burdens of illness and strategies for prevention
or management. Drugs Today (Barc) 36(11):773-784.
Obesity is implicated as a perpetuating factor in low back pain,
hypertension, metabolic syndrome, fatigue, dyspnea, and
obstructive sleep apnea.
Leavitt F, Katz RS. 2012. Lexical memory deficit in fibromyalgia syndrome. J Musculoskel Pain. 20(2):82-86. "Abnormalities in naming speed and phonemic verbal fluency are prominent clinical features of FMS and appear closely linked. Inferences derived from these abnormalities have the potential to transform our picture of how cognition in FMS dysfunctions. Deficits in lexical memory may signal a core area of cognitive deficiency in FMS." These authors have called attention to yet another variety of cognitive deficit that is common to FM patients.
Leavitt F, Katz RS. 2011. Development of the Mental Clutter Scale. Psychol Rep. 109(2):445-452. "Mental fog is a core symptom of fibromyalgia. Its definition and measurement are central to an understanding of fibromyalgia-related cognitive disability. The Mental Clutter Scale was designed to measure mental fogginess. In an exploratory factor analysis of two different samples (n=128 and n=170), cognitive symptoms of fibromyalgia loaded on 2 dimensions: cognition and mental clarity. The mental clarity factor comprised 8 items with factor loadings greater than .60 and was named the Mental Clutter Scale. The factor stability of the new scale was good, internal consistency was .95, and test-retest reliability over a median of 5 days was .92. The 8-item scale is a quick measure of mental fog that provides clinicians with information about cognitive functioning in fibromyalgia."
Leavitt F, Katz RS. 2009.
Normalizing memory recall in fibromyalgia with rehearsal: a
distraction-counteracting effect. Arthritis Rheum.
61(6):740-744. “In the absence of rehearsal, a source of
distraction added to unrefreshed information signals a
remarkable level of cognitive deficit in FMS that goes
undetected by conventionally relied-upon neurocognitive
Leavitt F, Katz RS, Mills M et al. 2002.
Cognitive and dissociative manifestations in fibromyalgia.
J Clin Rheumatol. 8(2):77-84. “These findings suggest
that dissociation may play a role in FM symptom amplification
and may aid in comprehending the regularity of cognitive
symptoms. Separating cases of fibrofog from cognitive
conditions with actual brain damage is important. It may
be prudent to add a test of dissociation as an adjunct to the
evaluation of FM patients in cases of suspected fibrofog.
Otherwise, test results may prove normal even in patients with
disabling cognitive symptoms.”
Leavitt F, Katz RS. 2006.
Distraction as a key determinant of impaired memory in patients
with fibromyalgia. J Rheumatol. 33(1):127-132.
“The findings validate the perception of failing memory in
patients with FM and are the first psychometric based evidence
to our knowledge of short-term memory problems in FM linked to
interference from a source of distraction. Adding a source
of distraction caused the majority of FM patients to retain new
information poorly and may be integral to an understanding of FM
Lebiebici B, Pektas ZO, Ortancil O et
al. 2006. Coexistence of fibromyalgia, temporomandibular
disorder, and masticatory myofascial pain syndromes. [Nov
10 Epub ahead of print] Rheumatol Int “Our
results indicate that coexistence of FM and TMD with MMP is
high. Pain and tenderness in the masticatory muscles
appear to be an important element in FM, so in some patients it
may be the leading complaint.”
H., I. Florence, R. Bathina, V. Hunko, M. T. Fox and C. Y.
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Lee, J. R.
1991. Is natural progesterone the missing link in
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Lee KJ, Kim JH, Cho SW. 2005.
Gabapentin reduces rectal mechanosensitivity and increases
rectal compliance in patients with diarrhea-predominant
irritable bowel syndrome. Aliment Pharmacol Ther.
22(10):981-988. “Our results show that gabapetin reduces
rectal sensory thresholds through attenuating rectal sensitivity
to distension and enhancing rectal compliance in
diarrhea-predominant irritable bowel syndrome patients.”
[This meshes with findings of central sensitization in IBS
Lee MC, Wanigasekera V, Tracey I. 2013. Imaging opioid analgesia in the human brain and its potential relevance for understanding opioid use in chronic pain. Neuropharmacology. [Jul 25 Epub ahead of print]. "Opioids play an important role for the management of acute pain and in palliative care. The role of long-term opioid therapy in chronic non-malignant pain remains unclear and is the focus of much clinical research. There are concerns regarding analgesic tolerance, paradoxical pain and issues with dependence that can occur with chronic opioid use in the susceptible patient. In this review, we discuss how far human neuroimaging research has come in providing a mechanistic understanding of pain relief provided by opioids, and suggest avenues for further studies that are relevant to the management of chronic pain with opioids."
Lee MJ, Chung YS. 2013. Spinal subarachnoid hematoma as a complication of an intramuscular stimulation: case report and a review of literatures. J Korean Neurosurg Soc. 54(1):58-60.
"Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery."
Lee SJ, Kim DY, Chun MH et al. 2012. The effect of repetitive transcranial magnetic stimulation on fibromyalgia: a randomized sham-controlled trial with 1-mo follow-up. Am J Phys Med Rehabil. 91(12):1077-1085. "In the low-frequency group, the Beck Depression Inventory scores significantly decreased from baseline to 1 mo after rTMS. The visual analog scale and Korean version of the Fibromyalgia Impact Questionnaire scores significantly decreased immediately after rTMS. In the high-frequency group, the visual analog scale and Beck Depression Inventory scores were significantly decreased immediately after rTMS....
Low-frequency rTMS may play a role in the long-term treatment of fibromyalgia. Notably, the findings of this study are the first to show that the right dorsolateral prefrontal cortex or the left motor cortex rTMS could have an antidepressive and pain-modulating effect in patients with fibromyalgia."
Lee SS, Yoon HJ, Chang HK et al. 2005.
Fibromyalgia in Behcet’s disease is associated with anxiety and
depression, and not with disease activity. Clin Exp
Rheumatol. 23(4 Suppl 38):S15-19. “FM (fibromyalgia)
was very common among BD (Behcet’s Disease) patients and was
associated with the presence of anxiety and depression, and not
with disease activity.” [Multiple invisible illnesses
(especially if one or more is undiscovered and untreated for a
number of years and causes a chronic pain state) have a greater
chance to cause depression, and this must be taken into account.
Lee YC. 2013. Effect and treatment of chronic pain in inflammatory arthritis. Curr Rheumatol Rep. 15(1):300. "Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. The prevalence of chronic, non-inflammatory pain syndromes such as fibromyalgia is higher among patients with inflammatory arthritis than in the general population. Inflammatory arthritis patients with fibromyalgia have higher measures of disease activity and lower quality of life than inflammatory patients who do not have fibromyalgia. This review article focuses on current literature involving the effects of pain on disease assessment and quality of life for patients with inflammatory arthritis. It also reviews non-pharmacologic and pharmacologic options for treatment of pain for patients with inflammatory arthritis, focusing on the implications of comorbidities and concurrent disease-modifying antirheumatic drug therapy."
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as expected, proved to be inappropriate to express disease
activity in FM patients. DAS28 values for expressing
disease activity in RA patients may be flawed by coexisting
FM and should therefore be regarded with caution as high
pain levels more than impaired mood may lead to higher total
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43-year-old female experienced severe right lumbar, right
sacrum, and right acetabular pain and muscle spasms occurring
after playing a vigorous tennis match 16 years earlier.”
“By the time of presentation she also experienced right arm and
right upper back pain. A lumbar MRI scan showed an L4/5
disc bulge. Patrick’s, Yeoman’s and Kemp’s tests were
positive on her right side. She had an asymmetrical gait
pattern with a right hip hike, lateral shift and rotation of the
pelvis. Weakness of the left gluteus maximus, gluteus
medius, and right erector spinae muscles was present.
Motion palpation revealed several fixations. There was
tenderness to palpation of the right psoas muscle and a trigger
point in the right iliacus muscle.” “Incorporation of
active patient participation seemed to be a significant factor
in the resolution of the patient’s low back pain. Active
patient participation improved the quality of life for this
patient.” [It is a sad commentary that the patient had to
endure so many years of pain and dysfunction before finding a
care provider who could properly address the cause of her
Legrain V, Mancini F, Sambo CF et al. 2012. Cognitive aspects of nociception and pain. Bridging neurophysiology with cognitive psychology. Neurophysiol Clin. 42(5):325-336. "The event-related brain potentials (ERPs) elicited by nociceptive stimuli are largely influenced by vigilance, emotion, alertness, and attention. Studies that specifically investigated the effects of cognition on nociceptive ERPs support the idea that most of these ERP components can be regarded as the neurophysiological indexes of the processes underlying detection and orientation of attention toward the eliciting stimulus. Such detection is determined both by the salience of the stimulus that makes it pop out from the environmental context (bottom-up capture of attention) and by its relevance according to the subject's goals and motivation (top-down attentional control). The fact that nociceptive ERPs are largely influenced by information from other sensory modalities such as vision and proprioception, as well as from motor preparation, suggests that these ERPs reflect a cortical system involved in the detection of potentially meaningful stimuli for the body, with the purpose to respond adequately to potential threats. In such a theoretical framework, pain is seen as an epiphenomenon of warning processes, encoded in multimodal and multiframe representations of the body, well suited to guide defensive actions. The findings here reviewed highlight that the ERPs elicited by selective activation of nociceptors may reflect an attentional gain apt to bridge a coherent perception of salient sensory events with action selection processes."
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ability to perceive electric and electromagnetic exposure)
have been scientifically documented. People with
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causes is important.” Yet it neglects one of the most
common and easily treated; the myofascial TrP.
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Rheumatol Suppl. 75:29-37. This paper
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intractable, chronic, generalized pain condition.” The
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"The non-working (NW) women reported a significantly higher severity of symptoms compared with the working (W) women. The most important variable when differentiating the W from the NW women was social support from colleagues and employers. ...To change prevailing attitudes and values towards persons with a work disability, a process of active intervention involving staff is needed. Educating employers as to how a disability may influence a work situation, and the importance of social support, can be improved." [In the case of women who have such severe pain and other disabling pain and dysfunctions that they cannot work, is it necessary to find another reason that such women who aren't working have greater pain? Where is the logic here? DJS]
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It may provide clues as to how proprioception is affected by
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"This article describes current views on motor and sensory control of extraocular muscles (EOMs) based on anatomical data. The special morphology of EOMs, including their motor innervation, is described in comparison to classical skeletal limb and trunk muscles. The presence of proprioceptive organs is reviewed with emphasis on the palisade endings (PEs), which are unique to EOMs, but the function of which is still debated. In consideration of the current new anatomical data about the location of cell bodies of PEs, a hypothesis on the function of PEs in EOMs and the multiply innervated muscle fibres they are attached to is put forward." [Imagine the effects of TrPs in these muscles. DJS]
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biochemical inter-relationship between FM and TMD,
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Future studies would benefit by the inclusion of myofascial
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This is a very interesting study and a promising one.
Until quite recently, FM researchers were unaware of
myofascial TrPs and myofascial practitioners were largely
unaware of the central sensitization of FM and the need to
modify therapies to accommodate it when it occurs in their
patients. FM is the amplifier. TrPs are the pain
generators. There may be other pain generators, but
the TrPs in the fascia (myofascia and other wise) are there
and generating symptoms. There are many of us patients
with FM and CMP, and our needs cannot be met until
researchers understand the complexity that both of these
conditions together can create. It is refreshing to see
that the bridge is finally being built. DJS]
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Liu J, Wang XQ, Zheng JJ et al. 2012. Effects of Tai Chi versus Proprioception Exercise Program on Neuromuscular Function of the Ankle in Elderly People: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2012:265486. "Tai Chi is a traditional Chinese medicine exercise used for improving neuromuscular function. This study aimed to investigate the effects of Tai Chi versus proprioception exercise program on neuromuscular function of the ankle in elderly people...Sixty elderly subjects were randomly allocated into three groups of 20 subjects per group. For 16 consecutive weeks, subjects participated in Tai Chi, proprioception exercise, or no structured exercise. Primary outcome measures included joint position sense and muscle strength of ankle…Results: (1) Both Tai Chi group and proprioception exercise group were significantly better than control group in joint position sense of ankle, and there were no significant differences in joint position sense of ankle between TC group and PE group. (2) There were no significant differences in muscle strength of ankle among groups. (3) Subjects expressed more satisfaction with Tai Chi than with proprioception exercise program…. None of the outcome measures on neuromuscular function at the ankle showed significant change post training in the two structured exercise groups. However, the subjects expressed more interest in and satisfaction with Tai Chi than proprioception exercise."
Liu T, Ji RR. 2013. New insights into the mechanisms of itch: are pain and itch controlled by distinct mechanisms? Pflugers Arch. [May 1 Epub ahead of print]. "Itch and pain are closely related but distinct sensations. They share largely overlapping mediators and receptors, and itch-responding neurons are also sensitive to pain stimuli….Chronic itch results from dysfunction of the immune and nervous system and can manifest as neural plasticity despite the fact that chronic itch is often treated by dermatologists. While differences between acute pain and acute itch are striking, chronic itch and chronic pain share many similar mechanisms, including peripheral sensitization (increased responses of primary sensory neurons to itch and pain mediators), central sensitization (hyperactivity of spinal projection neurons and excitatory interneurons), loss of inhibitory control in the spinal cord, and neuro-immune and neuro-glial interactions. Notably, painful stimuli can elicit itch in some chronic conditions (e.g., atopic dermatitis), and some drugs for treating chronic pain are also effective in chronic itch."
Liu X, Miller YD, Burton NW et al. 2012. The effect of Tai Chi on health-related quality of life in people with elevated blood glucose or diabetes: a randomized controlled trial. Qual Life Res. [Nov 10 Epub ahead of print]. "The aim was to assess the effects of a Tai Chi-based program on health-related quality of life (HR-QOL) in people with elevated blood glucose or diabetes who were not on medication for glucose control." "The findings show that this Tai Chi program improved indicators of HR-QOL including physical functioning, role physical, bodily pain and vitality in people with elevated blood glucose or diabetes who were not on diabetes medication."
Liu YP, Liu S. 2013. Electrical nerve stimulation and the relief of chronic pain through regulation of the accumulation of synaptic Arc protein. Med Hypotheses. [Jun 3 Epub ahead of print]. "Electrical nerve stimulation (ENS) is used in clinical settings for the treatment of chronic pain, but the mechanism underlying its effects remains unknown. ENS has been found to mimic neural activity, inducing the accumulation of Arc in synapses. Activity-dependent synaptic accumulation of Arc protein has been shown to reduce synaptic strength by promoting endocytosis of the AMPA receptors in the synaptic membrane. These receptors play a decisive role in central sensitization, which is one of the main mechanisms underlying chronic pain. It is here hypothesized that ENS induces Arc expression in synapses, where Arc promotes endocytosis of membrane AMPARs that are up-regulated during chronic pain. High frequency and high intensity are characteristics of ENS, which may be effective in the treatment of chronic pain. Stimulation-site of ENS may also influence the outcome of ENS."
Liu ZJ, Yamagata K, Kuroe K et al. 2000.
Morphological and positional assessment of TMJ components and
lateral pterygoid muscle in relation to symptoms and occlusion
of patients with temporomandibular disorders. J Oral Rehabil
27(10):860-874. “These findings suggest that TMJ
internal derangements are more related to the positional changes
or spatial relationships of TMJ components but less to the
individual morphologies of TMJ osseous structures, disc and LP
(lateral pterygoid), as well as specific clinical symptoms and
D., Ryan, K.M., Gilson, A.M., Dahl, J.L. 2000. Trends in
medical use and abuse of opioid analgesics. Between 1990-1996
the use of all agents, with the exception of meperidine,
increased from between 19% and 59%. Drug abuse due to
opioids and narcotics increased by only 6.6%. As a
proportion of all drug abuse, narcotic abuse decreased by 2%
in the same period. Specifically, abuse of meperidine
decreased by 39%, oxycodeine by 29%, fentanyl by 59%, and
hydromorphine by 15%. There was a 3% increase in drug
abuse related to morphine.
Lobbezoo F, Visscher CM, Naeije M.
2004. Impaired health status, sleep disorders, and
pain in the craniomandibular and cervical spinal regions.
Eur J Pain 8(1):23-30. “Both musculoskeletal pain in
the trigemino-cervical area and widespread body pain are
associated with an increased impairment of health status.
Also, sleep disorders are frequently found in patients with
chronic pain in the craniomandibular and cervical spinal
regions as well as in patients with widespread pain.
The more painful areas there are, the likelier it is that
sleep disorders are present.”
H., R. J. Salvi, M. L. Coad, M. L. Towsley, D. S. Wack and B.
W. Murphy. 1998.The functional neuroanatomy of tinnitus:
evidence for limbic system links and neural plasticity. Neurology
Loeser JD. 2005. Quo Vadis. Poena.
J Musculoskeletal Pain 13(3). This editorial
pinpoints some problems in the development of the field of
chronic pain management. One is the use of pain
clinics as dumping grounds for complex cases. Much of
chronic pain is preventable, but it is not being prevented.
“Chronic illness will become the major health care issue in
the 21st century, as the population ages and
infectious diseases are better treated.” “...we will
need pain managements who have a broad overview of the
diagnostic and therapeutic strategies that will provide the
best possible outcomes.” “Payers and providers will
need to recognize that chronic pain is like diabetes: cure
is not the goal. Instead, management with the goal of
minimizing morbidity, improving function, and containing
costs is the optimal outcome.”
RF, Shakoor, N. 2003. Aging or osteoarthritis: which is
the problem? Rheum Dis Clin North Am
authors realize that OA is not an inevitable part of getting
old, and that the progression of structural deterioration in
OA may be prevented by improving neuromuscular function.
Structural damage does not always correspond to joint
deterioration, and proprioception is often involved, as is
muscle weakness and lack of balance. What is missing in
this article is often at the heart of these things: myofascial
Loevinger BL, Muller D,
Alonso C et al. 2007. Metabolic syndrome in women with
chronic pain. Metabolism 56(1):87-93. “Women
with chronic pain from fibromyalgia are at an increased risk
for metabolic syndrome...”
Loggia ML, Berna C, Kim J et al. 2013. Disrupted brain circuitry for pain-related reward/punishment in fibromyalgia. Arthritis Rheum. [Nov 7 Epub ahead of print]. "In this study we investigate potential dysregulation of the neural circuitry underlying cognitive and hedonic aspects of the subjective experience of pain such as anticipation of pain and of pain relief….FMRI was performed on 31 FM patients and 14 controls while they received cuff pressure pain stimuli on their leg, calibrated to elicit a pain rating of ~50/100. During the scan, subjects also received visual cues informing them of impending pain onset (pain anticipation) and pain offset (relief anticipation)….Patients exhibited less robust activations during both anticipation of pain and anticipation of relief within regions commonly thought to be involved in sensory, affective, cognitive and pain-modulatory processes. In healthy controls, direct searches and region-of-interest analyses in the ventral tegmental area (VTA) revealed a pattern of activity compatible with the encoding of punishment: activation during pain anticipation and pain stimulation, but deactivation during relief anticipation. In FM patients, however, VTA activity during pain and anticipation (of both pain and relief) periods was dramatically reduced or abolished….FM patients exhibit disrupted brain responses to reward/punishment. The VTA is a source for reward-linked dopaminergic/GABAergic neurotransmission in the brain and our observations are compatible with reports of altered dopaminergic/GABAergic neurotransmission in FM. Reduced reward/punishment signaling in FM may relate to the augmented central processing of pain and reduced efficacy of opioid treatments in these patients."
Loh, N. K.,
D. S. Dinner, N. Foldvary, F. Skobieranda and W.W. Yew. 1999.
Do patients with obstructive sleep apnea wake up with
headaches? Arch Intern Med 159(15):1765-8.
Augustyn M.N., Ascott-Evans B.H. The metabolic syndrome
— pathogenesis, clinical features and management. Cardiovasc
J S Afr 13(4):181-6. “The metabolic syndrome is a
highly prevalent clinical entity, which is often overlooked
and may have far-reaching health implications to the patient.
Up to 80% of patients with the metabolic syndrome die as a
result of cardiovascular complications. Insulin
resistance is the central component of this complex syndrome
and should be appropriately addressed to ensure the best
possible outcome for our patients.”
Lommel K, Kapoor S, Bamford J et al. 2009. Juvenile primary fibromyalgia syndrome in an
inpatient adolescent psychiatric population. Int J Adolesc
Med Health. 21(4):571-579. “Juvenile primary fibromyalgia is
highly prevalent in an adolescent inpatient psychiatric unit.
This possibility should be taken into consideration when chronic
complaints of pain are expressed by patients in this setting,
especially in those who have conduct-related issues. The
JPFS and abuse history requires further investigation.” [It is
hoped that more studies will be done on identifying early
warning signs of fibromyalgia and chronic myofascial pain. If
awareness of the importance of symptoms such as unrestorative
sleep and growing pain becomes recognized, perhaps we can keep
some of these patients from developing chronic pain conditions.
Long, D. M.,
M. BenDebba, W. S. Torgerson, R. J. Boyd, E. G. Dawson, R. W.
Hardy, J. T. Robertson, G. W. Sypert and C. Watts. 1996.
Persistent back pain and sciatica in the United States:
patient characteristics. J Spinal Disord
Lopez-Rodríguez MM , Fernandez-Martínez M, Mataran-Penarrocha GA et al. 2012. [Effectiveness of aquatic biodance on sleep quality, anxiety and other symptoms in patients with fibromyalgia.] Med Clin (Barc). [Dec 12 Epub ahead of print]. [Spanish] "Aquatic biodance contributed to improvements in sleep quality, anxiety, pain and other fibromyalgia symptoms."
Loram ID, Lakie MD, Di Giulio
I et al. 2009. The consequences of short range
stiffness and fluctuating muscle activity for proprioception
of postural joint rotations: the relevance to human
standing. J Neurophysiol. [May 6 Epub
ahead of print].
Lord, S. R.,
M. W. Rogers, A. Howland and R. Fitzpatrick. 1999.
Lateral stability, sensorimotor function and falls in older
people. J Am Geriatr Soc 47(9):1077-81.
Lorduy KM, Liegey-Dougall A, Haggard R et al. 2013. The Prevalence of Comorbid Symptoms of Central Sensitization Syndrome among Three Different Groups of Temporomandibular Disorder Patients. Pain Pract. [Jan 22 Epub ahead of print].
"Myofascial TMD is characterized by a high degree of comorbidity of symptoms of CSS and associated emotional distress." [Patients with TMD should be assessed for myofascial pain due to trigger points, fibromyalgia, and other possible co-existing conditions, and distinction must be made between a general use of the term "myofascial pain" to mean TMJ and myofascial pain due to trigger points. DJS]
H. Beck and B. Bromm. 1997. Cognitive performance,
mood and experimental pain before and during morphine-induced
analgesia in patients with chronic non-malignant pain. Pain
Loretan S, Duvoisin B, Scolozzi P. 2011. Unusual fatal petrositis presenting as myofascial pain and dysfunction of the temporal muscle. Quintessence Int. 42(5):419-422. "Petrositis is a rare and severe complication of acute otitis media and mastoiditis.... We report here the unusual case of an 86-year-old man who presented with a handicapping myofascial pain and dysfunction syndrome of the right temporal muscle as a heralding manifestation of an unusual form of petrositis. The patient progressively developed a retropharyngeal abscess, a right sphenoid sinusitis, and fatal meningitis..... This case demonstrated that (1) myofascial pain and dysfunction syndrome that does not respond to conventional treatments may suggest an unusual etiology and warrant further medical investigations and a detailed medical history and that (2) petrositis can manifest itself with atypical clinical symptoms and radiologic signs."
Lorton D, Lubahn CL, Estus C et al.
2006. Bidirectional communication between the brain and
the immune system: implications for physiological sleep and
disorders with disrupted sleep. Neuroimmunomodulation.
13(5-6):357-374. “The central nervous system (CNS) modulates
immune function by signaling target cells of the immune system
through autonomic and neuroendocrine pathways.
Neurotransmitters and hormones produced and released by these
pathways interact with immune cells to alter immune functions,
including cytokine production. Cytokines produced by cells
of the immune and nervous systems regulate sleep.
Cytokines released by immune cells, particularly
interleukin-1beta and tumor necrosis factor-alpha, signal
neuroendocrine, autonomic, limbic and cortical areas of the CNS
to affect neural activity and modify behaviors (including
sleep), hormone release and autonomic function. In this
manner, immune cells function as a sense organ, informing the
CNS of peripheral events related to infection and injury.
Equally important, homeostatic mechanisms, involving all levels
of the neuroaxis, are needed, not only to turn off the immune
response after a pathogen is cleared or tissue repair is
completed, but also to restore and regulate natural diurnal
fluctuations in cytokine production and sleep.” [This
shows the interactivity of sleep dysfunction and immune
dysfunction, common interactive diagnoses in patients with FM
and CMP. DJS]
Lotaif AC, Mitrirattanakul S, Clark GT.
2006. Orofacial muscle pain: new advances in concept and
therapy. J Calif Dent Assoc. 34(8):625-630. “The
probable mechanisms underlying chronic myogenous pains and
trigger points phenomena are discussed. Treatment options
of the myogenous masticatory pain conditions including physical
medicine modalities, as well as several types of pharmacologic
agents, are presented.”
Loth, S., B,
Petruson, G. Lindstedt and B. A. Bengtsson. 1998.
Improved nasal breathing in snorers increases nocturnal growth
hormone secretion and serum concentrations of insulin-like
growth factor 1 subsequently. Rhinology
Lotsch J, Geisslinger G, Tegeder I. 2009.
Genetic modulaton of the pharmacological treatment of pain.
Pharmacol Ther. [Jul 15 Epub ahead of print].
“Inadequately treated acute and chronic pain remains a major
cause of suffering and dissatisfaction in pain therapy. A
cause for the variable success of pharmacologic pain therapy is
the different genetic disposition of patients to develop pain or
to respond to analgesics. The patient’s phenotype may be
regarded as the result of synergistic or antagonistic effects of
several genetic variants concomitantly present in an individual.
Variants modulate the risk of developing painful disease or its
clinical course (e.g., migraine, fibromyalgia, low back pain).
Other variants modulate the perception of pain….” “Other
polymorphisms alter pharmacokinetic mechanisms controlling the
local availability of active analgesic molecules at their
effector sites (e.g., decreased CYP2D6 related prodrug
activation of codeine to morphine). In addition, genetic
variants may alter pharmacodynamic mechanisms controlling the
interaction of the analgesic molecules with their target
structures (e.g., opioids receptor mutations). Finally,
opioids dosage requirements may be increased depending on the
risk of drug addiction….” [This information is important
for care providers and for patients to understand. It may
explain much of the variance of response to medications. Sadly,
genetics are not often taken into consideration when drawing up
treatment plans. This can not only increase long-term cost, it
can greatly add to the possibility of multiple drug treatment
Lotsch J, Skarke C, Liefhold J et al.
2004. Genetic predictors of the clinical response to
opioid analgesics: clinical utility and future perspectives.
Clin Pharmacokinet. 43(14):983-1013. Genetics can
affect analgesic response to opioids (some patients may need
higher doses to achieve the desired analgesia), affect
metabolism of opioids, or cause drug reactions.
Loucks TM, De Nil LF. 2006.
Anomalous sensorimotor integration in adults who
stutter: a tendon vibration study. Neurosci
Lett. [May 11 Epub ahead of print] “AWS (adults who
stutter) use proprioceptive information less efficiently
than normal speakers, which could interfere with
sensorimotor integration during speech production.”
[This study did not evaluate patients for myofascial
TrPs, which can often cause proprioceptive dysfunction,
although it does mention that movement dysfunction is
often associated with stuttering. Some cases of
stuttering may be related to myofascial TrPs, but
studies are needed on this. DJS]
K., M. Ruhl and E. Field. 1997. Ability to reproduce head
position after whiplash injury. Spine.
Louter MA, Bosker JE, van Oosterhout WP et al. 2013. Cutaneous allodynia as a predictor of migraine chronification. Brain. [Sep 29 Epub ahead of print]. "Cutaneous allodynia is a risk factor for migraine chronification and may warrant preventive treatment strategies."
Lovati C, Mariotti C, Giani L et al. 2013. Central sensitization in photophobic and non-photophobic migraineurs: possible role of retino nuclear way in the central sensitization process. Neurol Sci. 34 Suppl 1:133-135. "Overall, these findings suggest that light stimulation may contribute to central sensitization of pain pathways in migraineurs, possibly contributing to progression into chronic forms. The possible connections underlying this type of sensitization are offered by the recently published data on a non-image-forming visual retino-thalamo-cortical pathway which may allow photic signals to converge on a thalamic region which is selectively activated during migraine headache."
Lovy, M. R.,
G. Starkebaum and S. Uberoi. 1996. Hepatitis C infection
presenting with rheumatic manifestations: a mimic of
rheumatoid arthritis. J Rheumatol 23(6):979-983.
Low LA, Schweinhardt P. 2012. Early Life Adversity as a Risk Factor for Fibromyalgia in Later Life. Pain Res Treat. 2012:140832. "This paper discusses risk factors from early life that may increase the occurrence or severity of FM in later life: pain experience during neonatal life causes long-lasting changes in nociceptive circuitry and increases pain sensitivity in the older organism; premature birth and related stressor exposure cause lasting changes in stress responsitivity; maternal deprivation affects anxiety-like behaviors that may be partially mediated by epigenetic modulation of the genome-all these adult phenotypes are strikingly similar to symptoms displayed by FM sufferers. In addition, childhood trauma and exposure to substances of abuse may cause lasting changes in developing neurotransmitter and endocrine circuits that are linked to anxiety and stress responses."
JC, Yellin J, Honeyman-Lowe G. 2006. Female
fibromyalgia patients: lower resting metabolic rates than
matched healthy controls. Med Sci Monit.
12(7):CR282-289. This study indicates that FMS
patients have a low metabolic rate, adjusted for patient fat
percentage differential. The study also reiterates
what other research has found: that TSH, FT(4) and FT(3)
values are not reliable indicators in FMS patients.
J.C., Honeyman-Lowe, G. 1999. Ultrasound treatment of trigger
points: differences in technique for myofascial pain syndrome
and fibromyalgia patients. This is a report of clinical
experience described in terms of an experimental approach
without presentation of hard data. The details of treatment
depend strongly on what the patient feels. The caveat
that FMS patients are prone to be hyperreactive to ultrasound
therapy and need to be treated less vigorously is consistent
with their strong reaction to other treatments and life
experiences. It takes much more skill and gentleness to
successfully treat MTrPs of FMS patients than uncomplicated
J. C. and G. Honeyman-Lowe. 1998. Facilitating the
decrease in fibromyalgic pain during metabolic rehabilitation:
an essential role for soft tissue therapies. J
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Lowe, J. C.,
M .E. Cullum, L. H. Graf Jr., J. Yellin. 1997. Mutations
in the c-erbA beta gene: do they underlie euthyroid
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Lu X, Hui-Chan CW, Tsang WW. 2012. Tai Chi, arterial compliance, and muscle strength in older adults. Eur J Prev Cardiol. [Apr 4 Epub ahead of print]. "Aerobic exercise can alleviate the declines in arterial compliance common in older adults. However, when combined with strength training, aerobic exercise may not reduce arterial compliance….Tai Chi practitioners showed significantly better haemodynamic parameters than the controls as indexed by larger and small artery compliance. They also demonstrated greater eccentric muscle strength in both knee extensors and flexors….The findings of better muscle strength without jeopardizing arterial compliance suggests that Tai Chi could be a suitable exercise for older persons to improve both cardiovascular function and muscle strength."
Lubiatowski P, Romanowski L, Kruczynski
J et al. 2003. Proprioception in pathophysiology and
treatment of shoulder instability. Ortop Traumatol
Rehabil. 5(4):421-425. “Restoration of joint
proprioception and neuromuscular control seems to be an
essential part of treatment in shoulder instability.”
[This may be accomplished, at least in part, by treatment of
co-existing MTPs. DJS]
Lucas KR, Rich PA, Polus BI. 2010. Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: The effects of Latent Myofascial Trigger Points. Clin Biomech (Bristol, Avon). [Jul 26 Epub ahead of print]. Latent myofascial trigger points can cause major dysfunction and must be taken seriously.
Lucas KR, Rich PA, Polus BI. 2007.
Do latent trigger points affect muscle activation patterns?
J Musculoskel Pain 15 (Supp 13):30 item 49. [Myopain
2007 Poster] “LTrPs (latent trigger points) alter the
timing of muscle activation in common movement patterns
suggesting that they should be treated. Mechanisms that
might mediate the effects observed are proposed.” [Latent
MTPs cause muscle dysfunction and restriction of range of
motion, and may affect the way muscle function groups work
together. Care must be taken not to equate MTPs only with
pain. The dysfunction caused must be taken as seriously. DJS]
Macaskill P, Irwig L et al. 2009. Reliability of physical
examination for diagnosis of myofascial trigger points: a
systematic review of the literature. Clin J Pain.
25(1):80-89. This article was based on review of
literature. Myofascial medicine takes time, training and
experience. Most care providers do not have these. This must
DS. 2003. Diet and development of the insulin resistance
syndrome. Asia Pac J Clin Nutr 12 Suppl:S4. “Among
modifiable factors including weight loss and exercise,
dietary composition appears to have an important effect on
development of IRS. The available evidence suggests that
IRS, and therefore diabetes and cardiovascular disease, can
be prevented by a high fiber/low glycemic index diet
containing dairy products and a higher amount of unsaturated
fat than currently recommended.”
Ludwig, DS, JA Majzoub, A Al-Zahrani, GE Dallal, I Blanco and
SB Roberts. 1999. High glycemic index foods,
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J. Smith, D. Longo. 2002. The relationship of alexithymia to
pain severity and impairment among patients with chronic
myofascial pain. Comparisons with self-efficacy,
catastrophizing, and depression. Difficulty in recognizing,
accepting and describing emotional reactions to myofascial
pain symptoms and their impact correlates with the suffering
component of the illness, independent of self-efficacy or
Lund, B. C.,
K. A. Bever-Stille and P. J. Perry. 1999.
Testosterone and andropause: the feasibility of testosterone
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Kendall SA, Janerot-Sjoberg B et al. 2003. Muscle
metabolism in fibromyalgia studied by P-31 magnetic resonance
spectroscopy during aerobic and anaerobic exercise. Scand
J Rheumatol 32(3):138-145. “Fibromyalgia patients
seem to utilize less of the energy rich phosphorus metabolites
at maximal work despite pH reduction. They seemed to be
less aerobically fit and reached the anaerobic threshold
earlier than the controls.”
Bengtsson A, Thorborg P. 1986. Muscle tissue oxygen
pressure in primary fibromyalgia. Scand j Rheumatol.
15(2):165-173. “The conclusion is that in patients with
primary fibromyalgia, the muscle oxygenation is abnormal or low,
at least in the trigger point area of the muscles.” [These
findings may have been due to co-existing myofascial TrPs
creating microcirculation problems and energy crises. They must
learn that trigger points are NOT part of fibromyalgia but are
rather part of myofascial pain, a totally different condition.
Researchers must consider co-existing TrPs as possible cause of
what they are attributing to FM, or their conclusions will
remain faulty and suspect and generate more faulty research
based upon them. DJS]
Lundberg G, Anderberg UM,
Gerdle B. 2009. Personality features in female
fibromyalgia syndrome. J Musculoskel Pain.
Lundberg M, Larsson M, Ostlund H et al.
2006. Kinesiophobia among patients with musculoskeletal
pain in primary healthcare. J Rehabil Med.
38(1):37-43. “…factors that seemed to be associated with
kinesiophobia were interference, disability, pain severity, pain
intensity, life control, affective distress, depressed mood and
solicitous response. The multiple logistic regression
analysis showed no significant associations.” “Kinesiophobia is
a commonly seen factor among patients with musculoskeletal pain,
which ought to be taken into consideration when designing and
performing rehabilitation programs.” [It is also important
to understand that myofascial TrPs cause pain at the end of the
range of motion, and it is logical for the patient to avoid
range of motion when there is pain at the end of that range of
motion. The TrPs must be treated and the range of motion
restored as much as possible so that the reason for the fear is
removed. Only then can remaining fear be considered as
true kinesiophobia. DJS]
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and deficits in information processing. A controlled
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Aalto, S. Taimela, H. Hurri, I. Pyykko and H. Alaranta.
1998. One-footed and externally disturbed two-footed
postural control in patients with chronic low back pain and
healthy subjects. A controlled study with follow-up.
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N. P. Nair, S. Briere, F. Maheu, M. T. Tu, M. Lemay, B. S.
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K. Caidahl , G. Johansson and B. Bake. 1990. Respiratory
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Schelling G, Stahl R et al. Diffuse Tensor Imaging
(DTI) danisotropic changes in the brain associated with
chronic low back pain. Radiological Society of North
America Conference 29 Nov 2006. Chicago IL. (Conf. Nov 26-Dec 1) “...chronification
of lower back pain is associated with cortical and
subcortical microstructural anisotropy changes .... these
results argue for plastic changes of the cingulate gyrus,
postcentral gyrus and the prefrontal cortex in chronic pain
processing.” There are microstructural changes in the
brains of chronic pain patients, and DTI may explain and map
some of what is happening in chronic pain.
G., E. Garrett, K. Y. Liang and J. C. Anthony. 1999.
Cannabis use and cognitive decline in persons under 65 years
of age. Am J Epidemiol 149(9):794-800.
Lynch JJ 3rd, Wade CL,
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acetylcholine agonist): anti-allodynia in a rat
chemotherapy-induced pain model. Eur J Pharmacol.
((R)-5-(2-azetidinylmethoxy)-2-chloropyridine is in a new
class of pain relievers. They work mainly by activating
nicotinic acetylcholine receptors in the neurons. This
medication blocks the main pain transmitter receptors (acute
and chronic pain) and also affects local pain signaling that
can contribute to central sensitization, without toxic side
effects. [Phase II human trials for acute and chronic
pain are about to begin on this medication which is a
synthetic variation of Epibatidine without the toxicity of
that compound. DJS]
Lynch ME, Campbell F. 2011. Cannabinoids for Treatment of Chronic Non-Cancer Pain; a Systematic Review of Randomized Trials. Br J Clin Pharmacol. [Mar 23 Epub ahead of print].
"Chronic non-cancer pain conditions included neuropathic pain, fibromyalgia, rheumatoid arthritis, and mixed chronic pain. Overall the quality of trials was excellent. Fifteen of the eighteen trials that met inclusion criteria demonstrated a significant analgesic effect of cannabinoid as compared to placebo, several reported significant improvements in sleep. There were no serious adverse effects. Adverse effects most commonly reported were generally well tolerated, mild to moderate in severity and led to withdrawal from the studies in only a few cases. Overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis. The context of the need for additional treatments for chronic pain is reviewed. Further large studies of longer duration examining specific cannabinoids in homogeneous populations are required."
Lyons KS, Jones KD, Bennett RM et al. 2013. Couple perceptions of fibromyalgia symptoms: The role of communication. Pain. [Jul 18 Epub ahead of print]. "The objectives of the current study were to 1) describe fibromyalgia patient-spouse incongruence regarding patient pain, fatigue, and physical function and 2) examine the associations of individual and interpersonal factors with patient-spouse incongruence. Two hundred four fibromyalgia patients and their co-residing partners rated the patient's symptoms and function. Multilevel modeling revealed that spouses, on average, rated patient fatigue significantly lower than patients. Couple incongruence was not significantly different from zero, on average, for pain severity, interference, or physical function. However, there was significant variability across couples in how they rated the severity of symptoms and function, and how much incongruence existed within couples. Controlling for individual factors, patient and spouse reports of communication problems were significantly associated with levels of couple incongruence regarding patient fatigue and physical function, albeit in opposing directions. Across couples, incongruence was high when patients rated communication problems as high; incongruence was low when spouses rated communication problems as high. An important within-couple interaction was found for pain interference suggesting couples who are similar on level of communication problems experience low incongruence; those with disparate ratings of communication problems experience high incongruence. Findings suggest the important roles of spouse response and the patient's perception of how well the couple is communicating. Couple-level interventions targeting communication or other interpersonal factors may help to decrease incongruence and lead to better patient outcomes."
C, Wu S, Li G et al. 2010. Comparison of miniscalpel-needle
release, acupuncture needling, and stretching exercise to
trigger point in myofascial pain syndrome. Clin J Pain.
26(3):251-7. “Myofascial pain syndrome (MPS) is one of the
most common causes of chronic musculoskeletal pain. Several
methods have been recommended for the inactivation of
trigger points (TrPs). We carried out this study to
investigate the effectiveness of miniscalpel-needle (MSN)
release and acupuncture needling and self neck-stretching
exercises on myofascial TrPs of the upper trapezius muscle.”
This study found “the effectiveness of MSN release for MPS
is superior to that of acupuncture needling treatment or
self neck-stretching exercises alone. The MSN release is
also safe, without severe side effects in treatment of MPS.”
[The comparison may look good, but there are numerous
techniques that may be at least as effective. Stretching
alone is not an adequate treatment for TrPs in my opinion,
and I would like to see this technique compared with the
Travell and Simons’ technique (incorporating proper
positioning and full range of moti) of TrP injection with
procaine or lidocaine, barrier release and spray and
stretch. It is important to remember that no matter what the
technique employed, control of perpetuating factors is
critical to lasting treatment effect. DJS]
Ma Y, Bu H, Jia JR et al. 2012. [Progress of research on acupuncture at trigger point for myofascial pain syndrome] 32(6):573-576. [Chinese]. This literature review covered acupuncture used on TrPs, taking into consideration both Traditional Chinese Medicine and modern clinical research applications. This review indicates that acupuncture on specific myofascial TrPs can significantly affect myofascial pain, but that results could be influenced by a number of variables including needle size and needling technique. Existing studies are insufficient and inconsistent, with inadequate use of clinical diagnostic standards. Good studies are needed.
R. L. and C. S. Mabry. 2000. Allergic fungal sinusitis:
the role of immunotherapy Otolaryngol Clin North Am 33(2):433-440.
MacDougall HG, Moore ST, Black RA
et al. 2009. On-road assessment of driving performance in
bilateral vestibular-deficient patients. Ann N Y Acad
Sci. 1164:413-418. “This has important implications
for driver licensing, road-safety policy, and for the potential
successful rehabilitation of vestibular patients. Patients
with unilateral vestibular dysfunction may have more difficulty
driving than their bilateral counterparts.” [This can be
critical, as many patients with FM may have co-existing
vestibular dysfunction. DJS]
Macedo JA, Hesse J, Turner JD et al.
2007. Adhesion molecules and cytokine expression in
fibromyalgia patients: increased L-selectin on monocytes and
neutrophils. J Neuroimmunol. [Jun 27 Epub
ahead of print] “This study shows a slight disturbance in the
innate immune system of FM patients and suggests an enhanced
adhesion and recruitment of leukocytes to inflammatory sites.”
Macgregor J, von Schweinitz DG. 2006.
Needle electromyographic activity of myofascial trigger
points and control sites in equine cleidobrachialis muscle –
an observational study. Acupunct Med.
24(2):61-70. “Equine myofascial trigger points can be
identified and have similar objective signs and
electrophysiological properties to those documented in human
and rabbit skeletal muscle tissue. The important
differences from findings in human studies are that referred
pain patterns and the reproduction of pain profile cannot be
determined in animals."
Madeleine P, Vangsgaard S, Hviid Andersen J et al. 2013. Computer work and self-reported variables on anthropometrics, computer usage, work ability, productivity, pain and physical activity. BMC Musculoskel Disord 14:226. "The differences in pain characteristics, i.e., higher intensity, longer duration and more pain locations as well as poorer work ability reported by women workers relate to their higher risk of contracting WMSD (work-related musculoskeletal disorders). Overall, this investigation confirmed the complex interplay between anthropometrics, work ability, productivity, and pain perception among computer workers."
Madill SJ, McLean L. 2010. Intravaginal pressure generated during voluntary pelvic floor muscle contractions and during coughing: the affect of age and continence status. Neurolog Urodyn 29(3):437-442. As they age, women often recruit pelvic floor muscles to compensate for weakness in the urethral sphincter or fascia. [This can lead to increasing symptoms, as tight pelvic floor muscles due to TrPs are a common cause of stress incontinence. DJS]
K, Clark GT, Kuboki T. 2002. Intramuscular hypoperfusion,
adrenergic receptors, and chronic muscular pain. Aug
3(4):251-260. This review focuses on the sympathetic
connection between fibromyalgia and myofascial pain. The
authors state “What cannot be done at this time and is
needed in the future is to compare and contrast to what degree
the regional muscle pain disorder (myofascial) is similar or
different from the more generalized disorder
(fibromyalgia.)” I agree that it must be done. I
also think that it can be.
M., I. Libbrecht, F. Van Hunsel, A. H. Lin, L. De Clerck, W.
Stevens, G. Kenis, R. de Jongh, E. Bosmans and H. Neels. 1999.
The immune-inflammatory pathophysiology of fibromyalgia:
increased serum soluble gp130, the common signal transducer
protein of various neurotrophic cytokines.
Maes, M., A. Lin, S.
Bonaccorso, F. Van Hunsel, A. Van Gastel, L. Delmeire, M.
Biondi, E. Bosmans, G. Kenis and S. Scharpe. 1998. Increased
24-hour urinary cortisol excretion in patients with
post-traumatic stress disorder and patients with major
depression, but not in patients with fibromyalgia. Acta
Psychiatr Scand 98(4):328-35.
Maes M, Twisk FN, Johnson C. 2012. Myalgic Encephalomyelitis (ME), Chronic Fatigue Syndrome (CFS), and Chronic Fatigue (CF) are distinguished accurately: Results of supervised learning techniques applied on clinical and inflammatory data. Psychiatry Res. [Apr 20 Epub ahead of print]. "There is much debate on the diagnostic classification of Myalgic Encephalomyelitis (ME), Chronic Fatigue Syndrome (CFS) and chronic fatigue (CF). Post-exertional malaise (PEM) is stressed as a key feature. This study examines whether CF and CFS, with and without PEM, are distinct diagnostic categories. Fukuda's criteria were used to diagnose 144 patients with chronic fatigue and identify patients with CFS and CF, i.e. those not fulfilling the Fukuda's criteria. PEM was rated by means of a scale with defined scale steps between 0 and 6. CFS patients were divided into those with PEM lasting more than 24h (labeled: ME) and without PEM (labeled: CFS). The 12-item Fibromyalgia and Chronic Fatigue Syndrome (FF) Rating Scale was used to measure severity of illness. Plasma interleukin-1 (IL-1), tumor necrosis factor (TNF)α , and lysozyme, and serum neopterin were employed as external validating criteria. Using fatigue, a subjective feeling of infection and PEM we found that ME, CFS, and CF were distinct categories. Patients with ME had significantly higher scores on concentration difficulties and a subjective experience of infection, and higher levels of IL-1, TNFα, and neopterin than patients with CFS. These biomarkers were significantly higher in ME and CFS than in CF patients. PEM loaded highly on the first two factors subtracted from the data set, i.e. "malaise-sickness" and "malaise-hyperalgesia". Fukuda's criteria are adequate to make a distinction between ME/CFS and CF, but ME/CFS patients should be subdivided into ME (with PEM) and CFS (without PEM)."
Maeshima E, Furukawa K. 2012. A case of fibromyalgia syndrome with anaphylaxis induced by intradermal injection of purified protein derivative. Mod Rheumatol. [Jun 10 Epub ahead of print]. "When a 36-year-old woman with fibromyalgia syndrome (FMS) underwent the tuberculin test, urticaria developed on her trunk at 30 min after intradermal injection of purified protein derivative. Although the urticaria resolved, fever, facial edema, and generalized urticaria occurred after 8 h. A patient with FMS who developed a systemic allergic reaction after an intradermal skin test has not been reported. We should pay attention to anaphylactic reactions after intradermal injection in patients with FMS."
M, Moltoni L, Biasi G, Marcolongo R. 2000. Role of
intracellular calcium ions in the physiopathology of
fibromyalgia syndrome. Boll Soc Ital Biol Sper
(1-2:)1-4. "In fibromyalgia patients the intracellular
calcium concentration is significantly reduced in comparison
to that of healthy controls: the reduced intracellular calcium
concentration seems to be a peculiar characteristic of
fibromyalgia patients and may be potentially responsible for
Maggi RG, Mozayeni BR, Pultorak EL et al. 2012. Bartonella spp. Bacteremia and Rheumatic Symptoms in Patients from Lyme Disease-endemic Region. Emerg Infect Dis. 18(5):783-791. "Bartonella spp. infection has been reported in association with an expanding spectrum of symptoms and lesions. Among 296 patients examined by a rheumatologist, prevalence of antibodies against Bartonella henselae, B. koehlerae, or B. vinsonii subsp. berkhoffii (185 [62%]) and Bartonella spp. bacteremia (122 [41.1%]) was high. Conditions diagnosed before referral included Lyme disease (46.6%), arthralgia/arthritis (20.6%), chronic fatigue (19.6%), and fibromyalgia (6.1%). B. henselae bacteremia was significantly associated with prior referral to a neurologist, most often for blurred vision, subcortical neurologic deficits, or numbness in the extremities, whereas B. koehlerae bacteremia was associated with examination by an infectious disease physician. This cross-sectional study cannot establish a causal link between Bartonella spp. infection and the high frequency of neurologic symptoms, myalgia, joint pain, or progressive arthropathy in this population; however, the contribution of Bartonella spp. infection, if any, to these symptoms should be systematically investigated."
Magnusson, M. L., M.
H. Pope, L. Hasselquist, K. M. Bolte, M. Ross, V. K. Goel, J.
S. Lee, K. Spratt, C. R. Clark and D. G. Wilder. 1999.
Cervical electromyographic activity during low-speed rear
impact. Eur Spine J 8(2):118-25.
Magnussen, T. 1994.
Extra cervical symptoms after whiplash trauma. Cephalalgia
Magrey MN, Antonelli M, James N et al. 2013. High frequency of fibromyalgia in patients with psoriatic arthritis: a pilot study. Arthritis. [Feb 14 Epub ahead of print]. "FMS-associated pain and fatigue are significantly more frequent in patients with PsA compared to controls."
Mahakkanukrauh P, Surin P, Vaidhayakam P. 2005. Anatomical study of the pudendal nerve adjacent to the sacrospinous ligament. Clin Anat 18(3):200-205. The pudendal nerve can be entrapped in a variety of places. "Eight of fifteen rectal nerves pierced through the sacrospinous ligament, perhaps making it prone for entrapment." [Deep ligaments may be the site of TrP nerve entrapment. DJS]
Maher, J. 2000. Report
investigating the importance of head restraint positioning in
reducing neck injury in rear impact. Accid Anal Prev
Maher RM, Hayes DM, Shinohara, M. 2013. Quantification of dry needling and posture effects on myofascial trigger points using ultrasound shear-wave elastography. Arch Phys Med Rehabil. 94(11):2146-2150. "The shear modulus measured with ultrasound SWE (shear-wave elastography) reduced after DN (dry needling) and in the prone position compared with sitting, in agreement with reductions in palpable stiffness. These findings suggest that DN and posture have significant effects on the shear modulus of MTrPs, and that shear modulus measurement with ultrasound SWE may be sensitive enough to detect these effects."
Mahowald ML, Singh JA, Majeski P. 2005.
Opioid use by patients in an orthopedics spine clinic.
Arthritis Rheum. 52(1):312-321. “This study
provides clinical evidence to support and protect physicians
treating patients with chronic musculoskeletal diseases, who
may be reluctant to prescribe opioids because of possible
sanctions from regulatory agencies. More important, it
will benefit patients by permitting them to receive these
effective, safe medications.
Maiese K, Chong ZZ, Li F. 2005.
Driving cellular plasticity and survival through the
signal transduction pathways of metabotropic glutamate
receptors. Curr Neurovasc Res.
2(5):425-446. “Metabotropic glutamate receptor (mGluRs)…system
impacts upon neuronal, vascular, and glial cell function
and is activated by a wide variety of stimuli that
includes neurotransmitters, peptides, hormones, growth
factors, ions, lipids, and light. Employing signal
transduction pathways that can modulate both excitatory
and inhibitory responses, the mGluR system drives a
spectrum of cellular pathways that involve protein
kinases, endonucleases, cellular acidity, energy
metabolism, mitochrondrial membrane potential, caspases,
and specific mitogen-activated protein kinases.
Ultimately these pathways can converge to regulate
genomic DNA degradation, membrane phosphatidylserine
(PS) residue exposure, and inflammatory microglial
Doursounian L. 1997. Entrapment neuropathy of the medial
superior cluneal nerve. Nineteen cases surgically treated,
with a minimum of 2 years’ follow-up. Spine
22(10):1156-1159. “Nineteen patients suffering from unilateral
low back pain projecting in the territory of the medial superior
cluneal nerve, with a trigger point at the posterior iliac crest
and with a positive block test at this level, underwent surgery.
Results: Results were excellent in 13 cases (7 of which had
suffered from severe compression), and unsatisfactory in 6 cases
(including 4 cases in whom no compression could be
demonstrated). Conclusion: Entrapment neuropathy of the
medial superior cluneal nerve is a rare and easily treatable
cause of unilateral low back pain.”
Maigne R. 1991. Trigger point of the posterior iliac
crest: painful iliolumbar ligament insertion or cutaneous dorsal
ramus pain? An anatomic study. Arch Phys Med
Rehabil. 72(10):734-737. “A trigger point is
frequently found over the iliac crest at 7 to 8 cm from the
midline in low-back-pain syndromes.” “The iliac insertion
of the iliolumbar ligament is inaccessible to palpation, being
shielded by the iliac crest.” “The authors conclude that
the trigger point sometimes localized over the iliac crest at 7
cm from the midline likely corresponds to elicited pain from a
cutaneous dorsal ramus originating from the thoracolumbar
junction rather than from the iliac insertion of the iliolumbar
Maigne, R. 1997. Pain
syndromes of the thoracolumbar junction. Myofascial
Pain–Update in Diagnosis and Treatment. Phys Med Rehab
Clin North Am 8(1):87-100.
A, Papagapiou M, Umana M, Cohodarevic T, Nowak J, Nicholson K.
Unexplainable nondermatomal somatosensory deficits in patients
with chronic nonmalignant pain in the context of
litigation/compensation: a role for involvement of central
factors? J Rheumatol 2001 28(6):1385-93. Nondermatomal
somatosensory deficits (NDSD), commonly associated with
chronic pain conditions, may often be associated with
impairment of vibration, reduced strength, dexterity of
movement, and extreme sensitivity to superficial skin
palpation or profound insensitivity to deep pain. Spatial,
temporal, qualitative, and evolutionary patterns of NDSD
emerged associated with cognitive/affective symptoms.
Maitre M, Humbert JP, Kemmel V et
al. 2005. [A mechanism for gamma-hydroxybutyrate (GHB)
as a drug and a substance of abuse.] Med Sci
(Paris) 21(3):284-289. [French]
“Gamma-hydroxybutyrate (GHB) increases slow-wave deep
sleep and the secretion of growth hormone and besides
its role in anesthesia, it is used in several
therapeutic indications including alcohol withdrawal,
control of daytime sleep attacks and cataplexy in
narcoleptic patients and is proposed for the treatment
Maizels M, McCarberg B. 2005.
Antidepressants and antiepileptic drugs for chronic
non-cancer pain. Am Fam Physician
71(3):483-490. “The development of newer classes
of antidepressants and second-generation antiepileptic
drugs has created unprecedented opportunities for the
treatment of chronic pain. These drugs modulate
pain transmission by interacting with specific
neurotransmitters and ion channels... Tricyclic
antidepressants have documented (although limited)
efficacy in the treatment of fibromyalgia and chronic
low back pain. Recent evidence suggests that
duloxetine and pregabalin have modest efficacy in
patients with fibromyalgia.”
Majlesi J, Unalan H. 2004.
High-power pain threshold ultrasound technique in the
treatment of active myofascial trigger points: a
randomized, double blind, case-control study.
Arch Phys Med Rehabil 85:833-836. This study found
that high-power ultrasound, using a specific technique,
can quickly find and treat TrPs. [There was no
significant change in range of motion, which may
indicate that the TrPs were simply rendered latent, but
the pain levels were reduced significantly. This
therapy shows promise, although there are some areas in
which it cannot be utilized. DJS]
Majlesi J, uNalan H. 2004.
High-power pain threshold ultrasound technique in the
treatment of active myofascial trigger points: A
randomized, double-blind, case-control study. Arch Phys
Med Rehabil. 85(5):833-836. This technique was
more effective than conventional ultrasound.
Mak, M.K., Ng, P.L.
2003. Mediolateral sway in single-leg stance is the best
discriminator of balance performance for T’ai-Chi
practitioners. Arch Phys Med Rehabil
84(5):683-686. “T’ai-chi practitioners performed
better both in clinical and laboratory tests when compared
with subjects who did not practice T'ai Chi. More T'ai-Chi
experience was associated with better postural control.
[It may be helpful for patients with myofascial TrPs
who are t’ai chi players (and their medical team) to
remember this, persevere, and concentrate on TrPs that affect
mediolateral sway balance. DJS]
Podzolkov V.I., Napalkov D.A. 2002. [Metabolic syndrome from
the point of view of a cardiologist: diagnosis, non drug and
drug treatment.] Kardiologiia 42(12:91-7.
[Russian] “Timely diagnosis and treatment of metabolic
syndrome is important because of high prevalence of this
pathology....For correction of metabolic changes metformin is
used in addition to non drug methods which include diet and
exercise. Treatment with metformin allows to decrease
insulin resistance and thus severity of derangements of
metabolism. [Metformin is an inexpensive and useful part
of control of metabolic syndrome. DJS]
Wolff E. 2008. Evidence-informed management of chronic low
back pain with trigger point injections. Spine J.
8(1):243-252. “The management of chronic low back pain (CLBP)
has proven very challenging in North America, as evidenced by
its mounting socioeconomic burden. Choosing amongst
available nonsurgical therapies can be overwhelming for many
stakeholders, including patients, health providers, policy
makers, and third-party payers.” [Stakeholders? Why are
“stakeholders” making medical decisions? Shouldn’t medical
decisions be based on what is best for the patient? The vast
majority of chronic low back pain has been shown to be due to
myofascial TrPs. Training in diagnosis and treatment of same
would go far to relieve patient symptom and financial burden,
and actually help those stakeholders as proper myofascial
education would go far to relieving socioeconomic burden and
prevent future chronicity. Care providers, and “stakeholders,”
need to be educated in myofascial pain. DJS]
Malanga GA, Cruz Colon EJ. 2010. Myofascial low back pain: a review. Phys Med Rehabil Clin N Am. 21(4):711-724. Myofascia pain is common, found in up to 95% of chronic pain patients. TrPs can occur in muscle, fascia or tendons, and are often caused by muscle imbalance. [Often they are the cause of muscle imbalance DJS] There is a wide variety of treatment options, but steroids should not be used for TrP injection therapy.
GA, Gwynn MW, Smith R et al. 2002. Tizanidine is
effective in the treatment of myofascial pain syndrome.
Pain Physician 5(4):422-432.
Malhotra D, Saxena AK, Dar A+SA, et al. 2012. Evaluation of cytokine levels in fibromyalgia syndrome patients and its relationship to the severity of chronic pain. J Musculoskel Pain. 20(3):164-169. [Elevated levels of cytokines and other pro-inflammatory substances have been implicated in fibromyalgia. This study indicates that Interleukin-6, a pro-inflammatory substance, may be active in the process of increased pain in fibromyalgia. This indicates a possible role of inflammation in fibromyalgia. While not an inflammatory disease per se, IL-6, a pro-inflammatory cytokine, does affect glial cells as shown in the research of Dr. Linda Watkins and her team. [see Wieseler-Frank J, Maier SF, Watkins LR. 2005. Immune-to-brain communication dynamically modulates pain: physiological and pathological consequences. Brain Behav Immun. 19(2):104-111.] Pro-inflammatory cytokines can cause diffuse muscle aches, fatigue, hyperalgesia, depressed mood, and may other symptoms associated with FM. The authors urge large multicenter investigations, and explain that the exact role of inflammation in FM is not fully established. We hope for more research to follow up this excellent article. DJS]
Malin K, Littlejohn GO. 2012. Personality and fibromyalgia syndrome. Open Rheumatol J. 6:273-285. "No specific fibromyalgia personality is defined but it is proposed that personality is an important filter that modulates a person's response to psychological stressors. Certain personalities may facilitate translation of these stressors to physiological responses driving the fibromyalgia mechanism."
Malin K, Littlejohn GO. 2012. Psychological control is a key modulator of fibromyalgia symptoms and comorbidities. J Pain Res. 5:463-471. "FM patients use significantly different control styles compared with healthy individuals. Levels and type of psychological control buffer mood, stress, fatigue, and pain in FM. Control appears to be an important "up-stream" process in FM mechanisms and is amenable to intervention."
Malleson, P. N., M.
al-Matar and R. E. Petty. 1992. Idiopathic musculoskeletal
pain syndromes in children. J Rheumatol
Mallinson, A. I. and
N. S. Longridge. 1998. Dizziness from whiplash and head
injury: differences between whiplash and head injury. Am J
Malmberg, A. B., C.
Chen, S. Tonegawa and A.I. Basbaum. 1997. Preserved acute pain
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Karlberg M, Holmstrom E et al. 2010. Influence of prolonged
unilateral cervical muscle contraction on head repositioning
- decreased overshoot after a 5-min. static muscle
contraction task. Man Ther. [Jan 16 Epub ahead of
print]. “The ability to reproduce a specified head-on-trunk
position can be an indirect test of cervical proprioception.
This ability is affected in subjects with neck pain, but it
is unclear whether and how much pain or continuous muscle
contraction factors contribute to this effect….. After
contraction, the “…increased accuracy was most pronounced
for movements directed towards the activated side. Hence,
prolonged unilateral neck muscle contraction may increase
the sensitivity of cervical proprioceptors.” [It is known
that prolonged contraction can activate TrPs, and that they
are associated with proprioceptor dysfunction. DJS]
Mamelak M. 2000. The motor
vehicle collision injury syndrome. Neuropsychiatry
Neuropsychol Behav Neurol. 13(2):125-135.
“Occupants of motor vehicles involved in a collision often
develop a disabling syndrome consisting of head, neck and
back pain; impaired short-term memory and concentration;
fatigue and a loss of stamina; poor balance; and a change in
personality. Injury victims experience a loss of
motivation, emotional lability, and a decrease in libido.
It is hypothesized that the collision impact produces an
inertial strain injury to the anterior regions of the brain
which depresses the functions of the frontotemporal lobes,
at the same time, sensitizing somatosensory neural afferent
systems. Damage to the orbital surfaces of the
frontotemporal lobes, in particular, impairs the gating
mechanisms that normally limit sensory input to the brain
and further promotes central sensitization. Early
intervention to arrest the injury-induced metabolic cascade,
and treatment with agents that activate cerebral metabolism
may mitigate the symptoms of this injury syndrome.”
Manber, R. and R.
Armitage. 1999. Sex, steroids, and sleep: a review. Sleep
Manchikanti L. 2004. The growth of interventional pain
management in the new millennium: a critical analysis of
utilization in the Medicare population. Pain Physician.
7(4):465-482. “It is estimated that among Medicare
recipients, the frequency of interventional procedures, which
includes epidural, spinal neurolysis, and adhesiolysis
procedures; facet joint interventions and sacroiliac joint
blocks; and other types of nerve blocks excluding continuous
epidurals, implantables, disc procedures, intraarticular
injections, trigger point and ligament injections, had increased
by 95% from 1998 to 2003.” [The “bottom line” seems to be
the new criteria for medical management. Certainly, wiser
decisions must be made in the field of chronic pain. This
can best happen by education in interactive diagnoses rather
than reliance on differential diagnosis, and the inclusion of
myofascial pain and chronic pain management in all medical
Manco, M., G. Mingrone,
A. V. Greco, E. Capristo, D. Gniuli, A. De Gaetano and G.
Gasbarrini.2000. Insulin resistance directly correlates with
increased saturated fatty acids in skeletal muscle
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Mandal, A. C. 1984.
The correct height of school furniture. Physiotherapy
Mander BA, Rao V, Lu B et al. 2013. Prefrontal atrophy, disrupted NREM slow waves and impaired hippocampal-dependent memory in aging. Nat Neurosci. [Jan 27 Epub ahead of print]. "…findings suggest that sleep disruption in the elderly, mediated by structural brain changes, represents a contributing factor to age-related cognitive decline in later life." It is critical that quality as well a quantity of sleep be monitored in older adults, as quality of sleep directly relates to cognitive function. [A sleep study may uncover hidden reasons for (or contributions to) cognitive decline that may be treatable. DJS]
Manfredini D, Cocilovo F, Stellini E et al. 2013. Surface Electromyography Findings in Unilateral Myofascial Pain Patients: Comparison of Painful vs. Non Painful Sides. Pain Med. [Jun 7 Epub ahead of print]. OBJECTIVES: To answer the clinical research question: in patients with myofascial pain, are there any differences in the surface electromyography (sEMG) activity of muscles of the painful and nonpainful sides that can be detected by commercially available devices? RESULTS: At the study population level, differences between the sEMG values of muscles of the painful and nonpainful sides were not significant in any conditions, viz., either at rest or during clenching tasks. At the individual level, the difference between the sEMG activity of painful and nonpainful sides was very variable. CONCLUSIONS: The above findings were not supportive of the existence of any detectable difference in sEMG activity between jaw muscles of the painful and nonpainful sides in patients with unilateral myofascial pain. Centrally mediated mechanism for pain adaptation may explain these findings, and the role of sEMG as a diagnostic tool for muscle pain needs to be carefully reconceptualized.
Manfredini D, Tognini F, Montagnani G et al. 2004.
Comparison of masticatory dysfunction in temporomandibular
disorders and fibromyalgia. Minerva Stomatol.
53(11-12):641-650. “Most patients with fibromyalgia
(86.7%) report signs and symptoms localized at the
stomatognathic system; by contrast, only a minority of
patients with temporomandibular disorders (10%) are actually
affected by fibromyalgia.”
D, Cantini E, Romagnoli M et al. 2003. Prevalence of
bruxism in patients with different research diagnostic
criteria for temporomandibular disorders (RDC/TMD) diagnoses.
Bruxism has a stronger association with muscle
dysfunction than with disc and joint dysfunctions.
Patients with bruxism should be investigated for the presence
of muscle dysfunctions.
N, Jun HW, Beach JW et al. 2003. Solubility of
guaifenesin in the presence of common pharmaceutical
additives. Pharm Dev Technol 8(4):385-96.
Common additives can change the aqueous solubility of
guaifenesin. This indicates that all compounds of
guaifenesin may not have equal solubility and possibly may not
be equivalent in bioavailability as well.
Mann, J. J., K. M.
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hydroxylase gene with suicidal behavior in depressed patients.
Am J Psychiatry 154(10):1451-1453.
Mannerkorpi K, Gard G. 2012. Hinders for continued work among persons with fibromyalgia. BMC Musculoskelet Disord. 13(1):96. "Work disability is common among women with fibromyalgia (FM). The aim of the study was to investigate what health problems and work-related difficulties lead to hinders for continued work among women with FM.....Health problems and work-related demands were identified. Limited physical capacity, increased stress and an increased need of rest were the major health problems, while physical, psychosocial and work organizational demands were the main work-related problems. Personal factors and factors related to family influenced the strategies used to manage the imbalance between the health problems and work-related demands.....Limited physical capacity and an increased need of rest made it difficult for these women to manage the physical, psychosocial and organizational work demands. Adjustment of the work tasks and work environment were the main factors influencing whether the women with FM could work or not."
Mannerkorpi K, Nordeman L,
Ericsson A et al. 2009. Pool exercise for patients
with fibromyalgia or chronic widespread pain: a randomized
controlled trial and subgroup analyses. J Rehabil
Med. 41(9):751-760. “The exercise-education
program showed significant, but small, improvement in health
status in patients with fibromyalgia and chronic widespread
pain, compared with education only. Patients with
milder symptoms improved most with this treatment.”
Mannerkorpi K. 2005. Exercise in
fibromyalgia. Curr Opin Rheumatol. 17(2):190-194.
“The recent studies support existing literature on the
benefits of exercise for patients with fibromyalgia.
The outcomes appear to be related to the program design and
the characteristics of the populations studied. As the
patients with fibromyalgia form a heterogeneous population,
more research is required to identify the characteristics of
patients who benefit from specific modes of exercise.
Moreover, long-term planning is needed to motivate the
patients to continue regular exercise.”
K, Gard G. 2003. Physiotherapy group treatment for
patients with fibromyalgia – an embodied learning process. Disabil
This study found that “Interactions between the
co-participants promoted the process of creating new patterns
of thinking and acting in the social world” that were
beneficial to patients with fibromyalgia.
A good, positive support group may provide the same
thing to some degree.
K., Ahlmen M., Ekdahl C. 2002. Six- and 24-month
follow-up of pool exercise therapy and education for patients
with fibromyalgia. Scand J Rheumatol
study showed lasting improvements even 24 months after the
completion of the therapy. [It would be valuable to
evaluate the use of pool therapy in patients with both
fibromyalgia and chronic myofascial pain, and to specify which
pool temperatures are most effective. DJS]
Mannerkorpi, K., T.
Kroksmark and C. Ekdahl. 1999. How patients with fibromyalgia
experience their symptoms in everyday life. Physiother Res
Manor B, Lipsitz LA, Wayne PM et al. 2013. Complexity-based measures inform tai chi's impact on standing postural control in older adults with peripheral neuropathy. BMC Complement Altern Med. 13:87. Subjects of the Tai Chi program exhibited increased complexity of standing COP (control of posture) dynamics. These increases were associated with improved plantar sensation and physical function. Although more research is needed, results of this non-controlled pilot study suggest that complexity-based COP measures may inform the study of complex mind-body interventions, like Tai Chi, on postural control in those with peripheral neuropathy or other age-related balance disorders.
Manson J, Rotondi M, Jamnik V et al. 2013. Effect of tai chi on musculoskeletal health-related fitness and self-reported physical health changes in low income, multiple ethnicity mid to older adults. BMC Geriatr. 13(1):114. "Two hundred and nine ethnically diverse mid to older community dwelling Canadian adults residing in low income neighborhoods were enrolled in a 16 week Yang style TC program. Body Mass Index and select musculoskeletal fitness measures including upper and lower body strength, low back flexibility and self-reported physical health measured by SF 36 were collected pre and post the TC program. Determinants of health such as age, sex, marital status, education, income, ethnicity of origin, multi-morbidity conditions, weekly physical activity, previous TC experience as well as program adherence were examined as possible musculoskeletal health-related fitness change predictors….These results reveal that TC has the potential of having a beneficial influence on musculoskeletal health-related fitness and self-reported physical health in a mid to older low socioeconomic, ethnically diverse sample."
Mao J, Gold MS, Backonja MM. 2010. Combination Drug Therapy for Chronic Pain: A Call for More Clinical Studies. J Pain. [Sep 16 Epub ahead of print]. "Chronic pain is a debilitating clinical condition associated with a variety of disease entities including diabetic neuropathy, postherpetic neuralgia, low back pathology, fibromyalgia, and neurological disorders. For many general practitioners and specialists, managing chronic pain has become a daunting challenge. As a modality of multidisciplinary chronic pain management, medications are often prescribed in combinations, an approach referred to as combination drug therapy (CDT). However, many medications for pain therapy, including antidepressants and opioid analgesics, have significant side effects that can compound when used in combination and impact the effectiveness of CDT. To date, clinical practice of CDT for chronic pain has been based largely on clinical experiences. In this article, we will focus on (1) the scientific basis and rationales for CDT, (2) current clinical data on CDT, and (3) the need for more clinical studies to establish a framework for the use of CDT. ....More preclinical, clinical, and translational studies are needed to improve the efficacy of combination drug therapy that is an integral part of a comprehensive approach to the management of chronic pain." [Many of the conditions mentioned have as a common pain generator myofascial trigger points. Many TrP therapies are themselves painful. It is greatly to be hoped that, as we uncover the mechanisms of TrPs, useful medication regimens for chronic myofascial pain will be developed. DJS]
Maquet D, Croisier JL, Dupont C
et al. 2010. Fibromyalgia and related conditions: Electromyogram
profile during isometric muscle contraction. Joint Bone Spine.
[Apr 21 Epub ahead of print]. “OBJECTIVES: To evaluate
electromyogram (EMG) profiles in patients with three related
conditions: fibromyalgia, chronic fatigue syndrome, and
depression. METHODS: We studied 44 healthy volunteers, 22
patients with fibromyalgia, 11 patients with chronic fatigue
syndrome, and 10 patients admitted for depression. The trapezius
electromyogram was recorded during maximally sustained,
bilateral, 90 degrees abduction of the shoulders. EMG signal
frequency and amplitude were measured throughout the test.
RESULTS: In the fibromyalgia group, isometric contraction
duration was significantly shorter than in the other two patient
groups (P<0.001) and the EMG frequency and amplitude pattern
indicated premature discontinuation of the muscle contraction.
Findings in the chronic fatigue patients were similar to those
in the healthy controls. The patients with depression had a
distinctive EMG profile characterized by excessive initial
motor-unit recruitment with a shift in the frequency spectrum.
CONCLUSIONS: Fibromyalgia was associated with a specific EMG
pattern indicating premature discontinuation of the muscle
contraction. Therefore, maximal voluntary muscle contraction
tests may be of limited value for assessing function in
fibromyalgia patients. Chronic fatigue syndrome patients had
similar EMG findings to those in the healthy controls. The EMG
alterations in the patients with depression were consistent with
manifestations of psychomotor retardation.” [There is a great
likelihood that this study had nothing to do with FM and
everything to do with co-existing myofascial trapezius TrPs in
these FM patients. Studies of FM patients such as this one
must include assessment of TrPs to make any conclusions
D, Croisier JL, Renard C, Crielaard JM. 2002. Muscle
performance in patients with fibromyalgia. Joint Bone Spine
69(3):293-9. "This study of the three pathways supplying
energy to muscle confirms that muscle function is globally
impaired in FMS patients. The results suggest that the
impairment predominated on aerobic processes."
Marchettini, P., F.
Formaglio and M. Lacerenza. 1999. Clinical interpretations of
intraneural muscle nociceptors recordings in humans. J
Musculoskel Pain 7(1-2):55-59.
Marchioni D, Ghidini A, Daari S et al.
2005. The normal-weight snorer: polysomnographic study
and correlation with upper airway morphological alterations.
Ann Otol Rhinol Laryngol. 114(2):144-146. “The
major risk factor for developing OSAS in normal-weight
snorers appears to be anatomic abnormalities. The
normal-weight snorer needs to be thoroughly investigated
because of the significant risk of developing OSAS and for
the detection of multiple concomitant sites of obstruction.”
[This paper does not discuss muscle contracture due to TrPs,
but it could be a variable factor as well, and the presence
of TrPs in some muscle may indicate the need for
automatically adjusting CPAP set to maximum high equal to
that of the sleep study need of the patient.]
DA. 2009. Fibromyalgia: diagnosis and treatment
options. Gend Med. 6 Suppl 2:139-151.
“Physicians diagnose fibromyalgia in women at an
approximately 3- to 6-fold rate compared with men.”
“Fibromyalgia is a common, disabling, chronic pain condition
that predominantly affects women. Symptoms can be
effectively treated using both drug and nondrug therapies.
In general, treatment benefits in fibromyalgia appear
largely independent of patient sex.”
Marcus DA. 2006. A review of
perinatal acute pain: treating perinatal pain to reduce
adult chronic pain. J Headache Pain 7(1):3-8.
“Over the last decade, studies have suggested that exposure
to repeated painful procedures during the early perinatal
period results in profound changes in sensitivity of
nociceptive pathways. Both animal and human studies
show that early pain experiences increase pain responses
beyond the period of infancy. These data suggest a
need to increase implementation of guidelines for minimizing
pain exposures during infancy.”
Marcus, D. A. 2000.
Treatment of nonmalignant chronic pain. Am Fam Physician
Marcus DA, Bernstein CD, Constantin JM et al. 2012. Impact of Animal-Assisted Therapy for Outpatients with Fibromyalgia. Pain Med. [Nov 21 Epub ahead of print]. "Animal-assisted therapy using dogs trained to be calm and provide comfort to strangers has been used as a complementary therapy for a range of medical conditions. This study was designed to evaluate the effects of brief therapy dog visits for fibromyalgia patients attending a tertiary outpatient pain management facility compared with time spent in a waiting room. Brief therapy dog visits may provide a valuable complementary therapy for fibromyalgia outpatients."
Marcus DA, Bernstein CD, Haq A. 2013. Including a range of outcome targets offers a broader view of fibromyalgia treatment outcome: results from a retrospective review of multidisciplinary treatment. Musculoskeletal Care. [Jul 23 Epub ahead of print]. "Despite modest albeit statistically significant improvements in standard measures of pain severity and the FIQ (Fibromyalgia Impact Questionnaire), more substantial pain improvement was noted when utilizing alternative measures of pain and functional improvement. Alternative symptom assessment measures might be important outcome measures to include in drug and non-drug studies to better understand fibromyalgia treatment effectiveness."
Marcus DA, Richards KL, Chambers JF et al. 2012. Fibromyalgia Family and Relationship Impact Exploratory Survey. Musculoskeletal Care. [Nov 21 Epub ahead of print]. Fibromyalgia is frequently associated with impairments in activities of daily living and work disability. Limited data have investigated the impact of fibromyalgia on relationships with family and friends.....Half of participants endorsed that fibromyalgia had mildly to moderately damaged relationship(s) with their spouse(s)/partner(s) or contributed to a break-up with a spouse or partner. Half of participants scored as not being satisfied with their current spouse/partner relationship, with satisfaction negatively affected by the presence of mood disturbance symptoms and higher fibromyalgia severity. Relationships with children and close friends were also negatively impacted for a substantial minority of participants....In addition to physical impairments that are well documented among individuals with fibromyalgia, fibromyalgia can result in a substantial negative impact on important relationships with family and close friends.
Marcus NJ, Shrikhande AA, McCarberg B et al. 2013. A preliminary study to determine if a muscle pain protocol can produce long-term relief in chronic back pain patients. Pain Med. [May 20 Epub ahead of print]. This study was done on patients with neuraxal low back pain, testing before and after invasive treatments. They used an electrical device to find possible sources of pain, rather than palpation. The study found that identifying and treating painful muscles produced significantly lasting reductions in pain as well as function improvement. Some patients cancelled their surgeries. Others had failed back surgery, failed epidural steroid injections, and/or TrP injections. With treatment of muscle and tendon pain generator, their pain was significantly relieved using this muscle protocol. Both the muscles and their tendon attachments were critical pain generators.
Margoles M. 1983.
Stress neuromyelopathic pain syndrome (SNPS): Report of 333 patients.
J Neuro Ortho Surg 4(4):317-322. This is an older but very important study using the term “stress neuromyelopathic pain syndrome” for what Travell and Simons describe in their later texts as “post-traumatic hyperirritability syndrome.”
The authors agree that these are the same conditions. This condition can be caused by severe or repeated trauma especially to the head, neck and back, but can also be caused by biochemical trauma. This author found that patients with this condition often have low levels of B vitamins but may not respond to oral supplements, and 30-50% of these patients have abnormally high vitamin A.
Eating foods high in vitamin A could lead to a flaring of symptoms.
This condition often starts locally but can spread to overlapping pain patterns.
Clinical findings are clearly specified, and the fact that this can often be mistakenly diagnosed as neuropathy caused by disc problem when the disc is not the cause at all, but the metabolic changes that this syndrome has brought about.
[After extensive discussion with Drs. Michael S. Margoles and David G. Simons, I am convinced that these are early descriptions of what can happen when early myofascial trigger points and fibromyalgia are not treated promptly and aggressively.
This paper clearly describes in detail a scenario of the unfolding of this condition.
I advise any clinician to get a copy of this important paper. DJS]
Maria G, Cadeddu F, Brisinda D et al.
2005. Management of bladder, prostatic and pelvic
floor disorders with botulinum neurotoxin. Curr Med
Chem. 12(3):247-265. “Botulinum toxin (BoNT) has
been increasingly used in the interventional treatment of
several other disorders characterized by excessive or
inappropriate muscle contractions. BoNT is being
investigated for the control of the pain, and for the
management of tension or migraine headaches and myofascial
pain syndrome. This paper presents current data on the
use of BoNT to treat pelvic floor disorders.”
Marin, P., and S.
Arver. 1998. Androgens and abdominal obesity. Ballieres
Clin Endocrinol Metab 12(3):441-51.
Markkula R, Kalso E, Huunan-Sepp** et al. 2011. The burden of symptoms predicts early retirement: a twin cohort study on fibromyalgia-associated symptoms. Eur J Pain. [Feb 10 Epub ahead of print]. "…the high symptom class…had a 43%...increased overall mortality risk, which was fully accounted for by adjustment for lifestyle factors, mainly smoking." "Symptoms associated with FM strongly correlate with early disability retirement. Lifestyle problems associated with high symptom load need prompt management to avoid increased risk of mortality."
Markotic F, Cerni Obrdalj E, Zalihic A et al. 2013. Adherence to pharmacological treatment of chronic nonmalignant pain in individuals aged 65 and older. Pain Med. [Jan 31 Epub ahead of print]. "According to their own statements, 57% of the patients were nonadherent, while 84% exhibited some form of nonadherence …The most common deviation from the prescribed therapy was self-adjustment of the dose and medical regimen based on the severity of pain. Polymedication correlated positively with nonadherence. Nonsteroidal anti-inflammatory drugs were the most frequently prescribed medications. The majority of the participants (59%) believed that higher pain intensity indicates progression of the disease, and half of the participants believed that one can easily become addicted to pain medications. Nonadherence was associated with patient attitudes about addiction to analgesics and ability of analgesics to control pain….High pain intensity and nonadherence found in this study suggest that physicians should monitor older patients with chronic nonmalignant pain more closely and pay more attention to patients' beliefs regarding analgesics to ensure better adherence to pharmacological therapy." [Many patients have incorrect understanding of medications, and may fail to use sufficient medication to control their symptoms due to fear of addiction DJS]
Marqulis RK, Borrero M. 2010. Distant surgery scar points and fascial adhesions perpetuate pectoralis minor trigger points in two cases of severe chronic palmar pain. International Myopain Society Eighth Clinical Meeting Oct 3-7, 2010. Toledo, Spain. Abstract No. 91. "In these cases, the distant scar points and fascial adhesions on acupuncture channels acted as trigger point perpetuating factors: when these factors were successfully treated, the trigger points resolved and did not return. This is believed to be the first report of scar points and fascial adhesions as distant trigger point perpetuating factors." [Actually, previous significant research has been published on the topic of scars and TrPs by both Dr. Karl Lewit and Dr.Alena Kobesova. DJS]
Marshall R, Paul L, McFadyen AK et al. 2010. Pain characteristics of people with chronic fatigue syndrome. J Musculoskel Pain 18(2):127-137. People with chronic fatigue syndrome often have significant pain issues, and these must be treated by pain management strategies. Research has been focused on the fatigue, although five of the eight other symptoms commonly reported are pain-related. [Patients reported pain symptoms, including muscle tightness, associated with myofascial TrPs and nerve entrapment. It would be of great importance to find out the percentage of chronic fatigue syndrome patients who also have co-existing myofascial TrPs. Myofascial pain may be an important and treatable interactive condition contributing not only to the pain but also to the fatigue. DJS]
Martin DP, Sletten CD, Williams BA
et al. 2006. Improvement in fibromyalgia symptoms
with acupuncture: results of a randomized controlled
trial. Mayo Clin Proc. 81(6):749-757. “We
found that acupuncture significantly improved symptoms
of fibromyalgia. Symptomatic improvement was not
restricted to pain relief and was most significant for
fatigue and anxiety.” [The subset of FMs patients
who have anxiety and fatigue may benefit from specific
acupuncture therapy. DJS]
Martín J, Torre F, Padierna A et al. 2013. Interdisciplinary treatment of patients with fibromyalgia: Improvement of their health-related quality of life. Pain Pract. [Nov 27 Epub ahead of print]. "This interdisciplinary intervention has shown effectiveness in improving the HRQoL of this sample of patients with FM. The number of physical illnesses was identified as a predictor of that improvement."
Martin KL, Blizzard L, Srikanth VK et al. 2013. Cognitive Function Modifies the Effect of Physiological Function on the Risk of Multiple Falls--A Population-Based Study. J Gerontol A Biol Sci Med Sci. [Feb 14 Epub ahead of print]. "A range of cognitive (executive function/attention, memory, processing speed, and visuospatial ability) and physiological functions (vision, proprioception, sway, leg strength, reaction time) were measured using standardized tests in 386 randomly selected adults aged 60-86. Incident falls were recorded over 12 months….Preventing falls due to physiological impairments in community-dwelling older people may need to be tailored based on cognitive impairment, a key factor in their inability to compensate for physical decline."
Martin S, Chandran A, Zografos
L et al. 2009. Evaluation of the impact of
fibromyalgia on patients’ sleep and the content validity of
two sleep scales. Health Qual Life Outcomes.
7(1):64. “This study demonstrates the significant
impact that FM has on patients’ lives, particularly sleep.”
[A sleep study is an important part of FM evaluation, and
may uncover several treatable perpetuating factors that are
impacting the patient’s quality of life. DJS]
Martin, W. J., A. B.
Malmberg and A. I. Basbaum. 1998. Pain: nocistatin spells
relief. Curr Biol 8(15):R525-7.
Martinez MP, Miro E, Sanchez AI et al. 2013. Cognitive-behavioral therapy for insomnia and sleep hygiene in fibromyalgia: a randomized controlled trial. J Behav Med. [Jun 7 Epub ahead of print]. "The CBT-I (cognitive-behavioral therapy for insomnia) group reported significant improvements at post-treatment in several sleep variables, fatigue, daily functioning, pain catastrophizing, anxiety and depression. The SH (sleep hygiene) group only improved significantly in subjective sleep quality. Patients in the CBT-I group showed significantly greater changes than those in the SH group in most outcome measures. The findings underscore the usefulness of CBT-I in the multidisciplinary management of FM."
Martinez-Jauand M, Sitges C, Femenia J et al. 2013. Age-of-onset of menopause is associated with enhanced painful and non-painful sensitivity in fibromyalgia. Clin Rheumatol. 32(7):975-981. "Fibromyalgia (FM) is a chronic pain condition characterized by high prevalence in women. In particular, estrogen deficit has been considered as a potentially promoting factor of FM symptoms. This study was aimed to examine the relationship between age-of-onset of menopause and pain sensitivity in FM. For this purpose, pain sensitivity was assessed in 74 FM and 32 pain-free control women. All participants were postmenopausal and underwent a detailed semi-structured clinical interview, including data about menopause transition, previous history of hysterectomy or ovariectomy, and menses time. Participants were divided into two groups depending on age-of-onset of menopause: early menopause [<49 years] vs. late menopause [>49 years]. Pain and non-pain thresholds were assessed by using cold, heat, mechanical, and electrical stimulation. FM women showed higher overall pain sensitivity as compared with healthy subjects. FM women with early age-of-onset of menopause displayed greater pain and non-pain sensitivity than women with late age-of-onset of menopause, whereas no differences were observed in healthy women due to age-of-onset of menopause. These results suggest that an early transition to menopause (shortening the time of exposure to estrogens) may influence pain hypersensitivity and could be related to aggravation of FM symptoms."
Martinez-Jauand M, Sitges C, Rodriguez V et al. 2012. Pain sensitivity in fibromyalgia is associated with catechol-O-methyltransferase (COMT) gene. Eur J Pain. [Apr 24 Epub ahead of print]. "Recent evidence suggests that genetic factors might contribute to individual differences in pain sensitivity, risk for developing clinical pain conditions and efficacy of pain treatments. The purpose of the present study was to investigate the relationship of three common haplotypes of COMT gene affecting the metabolism of catecholamines on pain sensitivity in patients with fibromyalgia (FM)….According with previous research, our findings revealed that haplotypes of the COMT gene and genotypes of the Val158Met polymorphism play a key role on pain sensitivity in FM patients."
Martinez-Lavin M. 2012. Fibromyalgia: When Distress Becomes (Un)sympathetic Pain. Pain Res Treat. 2012:981565. [Epub 2011 Sep 19] "...in fibromyalgia, distress could be converted into pain through forced hyperactivity of the sympathetic component of the stress response system."
Martinez-Lavin M. 2004. Fibromyalgia as a
sympathetically maintained pain syndrome. Curr Pain
Headache Rep. 8(5):385-389. “...patients with FM
display signs of relentless sympathetic hyperalgesia...”
M. 2002. The autonomic nervous system, and fibromyalgia. J
Musculoskel Pain 10(1/2):221-228.
Fibromyalgia is a multisystem illness. Many researchers
have found indications that fibromyalgia is a form of
autonomic nervous system dysfunction.
M. 2002. Management of dysautonomia in fibromyalgia. Rheum
Dis Clin North Am 28(2):379-87. "The realization of
dysautonomia in FM has opened the possibility for new and
different therapeutic interventions. Much more research
is needed to better define the role of ANS in the pathogenesis
of FM. If this research supports current hypotheses,
therapeutic trials with disciplines and substances intended to
correct autonomic dysfunction will be indicated."
Martinez-Lavin, M., A.
G. Hermosillo, M. Rosas and M. E. Soto. 1998. Circadian
studies of autonomic nervous balance in patients with
fibromyalgia: a heart rate variability analysis. Arthritis
Martinez-Lavin, M., A.
G. Hermosillo, C. Mendoza, R. Ortiz, J. C. Cajigas, C. Pineda,
A. Nava, and M. Vallejo. 1997. Orthostatic sympathetic
derangement in subjects with fibromyalgia. J Rheumatol
Martino, A. M. 1998.
In search of a new ethic for treating patients with chronic
pain: What can medical boards do? J Law, Medicine &
Marwick, C. 1999. New
advocates of adequate treatment say have no fear of pain or of
prosecution. JAMA 281:406-407.
Masand, P. S. and S.
Gupta. 1999. Selective serotonin-reuptake inhibitors: an
update. Harv Rev Psychiatry 7(2):69-84.
Brown BR, Friedman S. 2003. Toothache of nonodontogenic
origin: a case report. J Endod. 29(9):608-610.
“This article describes the diagnosis and treatment of a patient
exhibiting nonodontogenic tooth pain. A 25-year-old female
patient presented to postgraduate endodontics, SUNY at Stony
Brook, for evaluation and treatment of pain associated with the
upper and lower left quadrants. After thorough intraoral
and extraoral examinations, it was determined that the pain was
referred to the dentition from a trigger point in the masseter
muscle. An extraoral injection of 3% Carbocaine was
administered into the trigger point, and the pain abated within
5 minutes. The patient has experienced no recurrence of
this pain for 12 months. Consideration of nonodontogenic
dental pain should be included in a differential diagnosis.”
Mascia P, Brown BR,
Friedman S. 2003. Toothache of nonodontogenic origin: a
case report. J Endod 29(9):608-10. These authors
found that a masseter trigger point was the source of tooth
pain in this patient. The patient had immediate relief
after trigger point injection, with no recurrence of the pain.
Dental practitioners need myofascial medicine as part of their
training and their differential diagnosis.
Masood, K., C. Wu, U.
Brauneis and F. F. Weight. 1994. Differential ethanol
sensitivity ofrecombinant N-methyl-D-aspartate receptor
subunits. Mol Pharmacol 45(2):324-329.
Masralla, M., J. Haier
and G. L. Nicolson. 1999. Multiple mycoplasmal infections
detected in blood of patients with chronic fatigue syndrome
and/or fibromyalgia syndrome. Eur J ClinMicrobiol Infect
Massa F, Storr M, Lutz B. 2005.
The endocannabinoid system in the physiology and
pathophysiology of the gastrointestinal tract.
J Mol Med. [August 26 Epub ahead of print ] “The
endocannabinoid system may serve as a potentially
promising therapeutic target against different GI
disorders, including frankly inflammatory bowel diseases
(e.g., Crohn’s disease), functional bowel diseases
(e.g., irritable bowel syndrome) and secretion- and
Massey PB. 2007. Reduction of
fibromyalgia symptoms through intravenous nutrient therapy:
results of a pilot clinical trial. Altern Ther
Health Med. 13(3):32-34. “IVNT appears to be safe to
reduce FM symptoms.” The patients in this study had FM for
at least 8 years and had no significant, lasting relief with
Mataran-Penarrocha GA, Castro-Sanchez AM, Garcia GC et al. 2009.
Influence of craniosacral therapy on anxiety, depression and
quality of life in patients with fibromyalgia. Evid
Based Complement Alternat Med. [Sep 3 Epub ahead of
print]. “Approaching fibromyalgia by means of
craniosacral therapy contributes to improving anxiety and
quality of life levels in these patients.”
[Craniosacral therapy can be a good way to integrate other
therapies and calm the sympathetic nervous system. DJS]
S, Zihl J, Steiger A et al. 2004. Effect of repeated
gaboxadol administration on night sleep and next-day
performance in healthy elderly subjects.
Neuropsychopharmacology Dec 15 [Epub ahead of print]
Gaboxadol improved sleep quality in healthy elderly subjects
L, Hirani SP, Epstein R et al. 2009. Laryngeal manual
therapy: a preliminary study to examine its treatment effects in
the management of muscle tension dysphonia. J Voice.
23(3):353-366. Manual therapy can often relieve what is called
“muscle tension dysphonia.” [This indicates that a significant
portion of the problem may be due to the presence of TrPs in the
laryngeal and related muscles. People working in this field
must be made aware of this situation. It would be a
win/win scenario for all concerned. DJS]
2009. [Somatic comorbidities in irritable bowel syndrome:
fibromyalgia, chronic fatigue syndrome, and interstitial
cystitis] Gastroenterol Clin Biol. 33 Suppl
1:S17-25. [French] “Fibromyalgia, chronic fatigue
syndrome, and interstitial cystitis frequently overlap with
irritable bowel syndrome (IBS). There is a positive
correlation between the incidence of these comorbidities and
increased health care seeking, reduction in quality of life, and
higher levels of mood disorders, which raises the question of a
common underlying pathophysiology. A possible central
hypersensitization disorder seems to be particularly involved in
the dysfunction of bidirectional neural pathways and
viscerovisceral cross-interactions within the CNS, thus
explaining these many extraintestinal manifestations in IBS.”
Matsuda JB, Barbosa FR, Morel LJ et al. 2010. [Serotonin receptor (5-HT 2A) and catechol-O-methyltransferase (COMT) gene polymorphisms: Triggers of fibromyalgia?] Rev Bras Reumatol. 50(2):141-145. [Portuguese] "The L/L genotype was more frequent among fibromyalgia patients. Though considering a polygenic situation and environmental factors, the molecular study of the rs4680 SNP of the COMT gene may be helpful to the identification of susceptible individuals."
Matsuda M, Imaoka T, Vomachka AJ et al. 2004.
Serotonin regulates mammary gland development via an autocrine-paracrine loop.
Dev Cell 6(2):193-203. Dysfunctional serotonin signaling may be part of the reason some women with FMS experience problems nursing.
Nursing may begin normally, but the milk [production] hesitates or stops.
Matsumoto, Y. 1999.
[Fibromyalgia syndrome]. Nippon Ronsho
Matsutani LA, Marques AP, Ferreira EA et
al. 2007. Effectiveness of muscle stretching exercises
with and without laser therapy at tender points for patients
with fibromyalgia. Clin Exp Rheumatol.
25(3):410-415. “Laser therapy has not shown advantages when
added to muscle stretching exercises.”
Matthana MH. 2011. The relation between Vitamin D deficiency and fibromyalgia syndrome in women. Saudi Med J. 32(9):925-929. "Vitamin D deficiency has to be considered in the management of fibromyalgia syndrome."
Matthews, D. A. , M.
E. McCullough, D. B. Larson, H. G. Koenig, J. P. Swyers and M.
G. Milano. 1998. Religious committment and health status: a
review of the research and implications for family medicine.
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Mau, W. and H. Zeidler.
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Mawe GM, Coates MD, Moses PL. 2006. Review article:
intestinal serotonin signaling in irritable bowel syndrome.
Aliment Pharmacol Ther. 23(8):1067-1076. “Both
genetic and epigenetic factors could contribute to decreased
serotonin-selective reuptake transporter in irritable bowel
syndrome. A serotonin-selective reuptake transporter
gene promoter polymorphism may cause a genetic
predisposition, and inflammatory mediators can induce
serotonin-selective transporter downregulation. While
a psychiatric co-morbidity exists with IBS, changes in
mucosal serotonin handling support the concept that there is
a gastrointestinal component to the aetiology of irritable
bowel syndrome.” [There are many patients with IBS and
without a “psychiatric component” except for the general
depression that one gets when one is given that “It’s All In
Your Head” diagnoses. Current research indicates that
chronic illness often has intestinal permeability as a
contributor. When patients have invisible illnesses
causing chronic pain and are given or take aspirin and NSAID
that can contribute to intestinal permeability (see Galland,
www.functionalmedicine.org), IBS is a logical
consequence. It is nice to know that some researchers
are finally discovering the GI component, but they are still
stuck in the mindset that IBS is a basically psychological
2009. [Chronic pain alters the structure of the brain.]
Schmerz. [Oct 17 Epub ahead of print] [German] “Local
morphologic alterations of the brain in areas ascribable to the
transmission of pain were recently detected in patients
suffering from phantom pain, chronic back pain, irritable bowel
syndrome, fibromyalgia and frequent headaches. These
alterations were different for each pain syndrome, but
overlapped in the cingulated cortex, the orbit frontal cortex,
the insula and dorsal pons. As it seems that chronic pain
patients have a common ‘brain signature’ in areas known to be
involved in pain regulation, the question arises whether these
changes are the cause or the consequence of chronic pain.
The in vivo demonstration of a loss of brain gray matter in
patients suffering from chronic pain compared to age and
sex-matched healthy controls could represent the heavily
discussed neuroanatomical substrate for pain memory.”
May. K. P. , S. G.
West, M. R. Baker and D. W. Everett. 1993. Sleep apnea in male
patients with the fibromyalgia syndrome. Am J Med
Mayer, E. A., R. Fass
and S. Fullerton. 1998. Intestinal and extraintestinal
Mayer-Davis, E. J. ,
R. D’Agostino Jr., A. J. Karter, S. M. Haffner, M. J. Rewers,
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physical activity on relation to insulin sensitivity: the
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Mayoral O, Salvat I, Martín MT et al. 2013. Efficacy of myofascial trigger point dry needling in the prevention of pain after total knee arthroplasty: a randomized, double-blinded, placebo-controlled trial. Evid Based Complement Alternat Med. 2013:694941. A single treatment of dry needling myofascial trigger points after anesthesia, before surgery for total knee arthroplasty, helped prevent residual pain. The pain was less for patients who had dry needling in the first month after surgery, and remained so at 6 month follow-up.
Mayoral del Moral O. 2010. Dry needling treatments for myofascial trigger points. J Musculoskel Pain. 18(4):411-416. "There exist different dry needling techniques that can be used in the treatment of trigger points. These techniques seem to be effective in treating this condition. There seems to be an increasing number of indications of these techniques within the context of myofascial pain syndrome. Dry needling techniques are rapidly expanding among healthcare providers. More research is needed to know the mechanisms of dry needling in order to improve its efficiency and the patients' tolerance of the techniques." There are multiple dry needling techniques, and all require training and experience.
McAdam, B. F., F.
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A. FitzGerald. 1999.
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(COX)-2: the human pharmacology of a selective inhibitor of
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McAllister SJ, Vincent A, Hassett AL et al. 2013. Psychological Resilience, Affective Mechanisms and Symptom Burden in a Tertiary-care Sample of Patients with Fibromyalgia. Stress Health. [Dec 26 Epub ahead of print.] "Our results suggest that improving affect through resiliency training could be studied as a modality for improving fibromyalgia symptom burden."
McAuley JH, Stanton TR, Kamper SJ et al. 2011. Psychological approaches have not been demonstrated to be effective for fibromyalgia. Pain. [Feb 10 Epub ahead of print].
McBeth J, Chiu YH, Silman AJ et al.
2005. Hypothalamic-pituitary-adrenal stress axis
function and the relationship with chronic widespread pain
and its antecedents. Arthritis Res Ther.
7(5):R992-R1000. “This is the first population study
to demonstrate that those with established, and those
psychologically at risk of, chronic widespread pain
demonstrate abnormalities of HPA axis function, which are
more marked in the former group.” “We conclude that
the occurrence of HPA abnormality in persons with chronic
widespread pain is not fully explained by the accompanying
McBeth, J., G. J.
Macfarlane, S. Benjamin, S. Morris and A. J. Silman. 1999. The
association between tender points, psychological distress, and
adverse childhood experiences: a community-based study. Arthritis
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pain syndrome type 1 and fibromyalgia syndrome.
Curr Rheumatol Rep. 11(6):461-465. “The
somatosensory system is an integral component of the motor
control system that facilitates the recognition of location
and experience of peripheral stimuli, as well as body part
position and differentiation. In chronic pain, this
system may be disrupted by alterations in peripheral and
cortical processing. Clinical symptoms that accompany
such changes can be difficult for patients to describe and
health care practitioners to comprehend. Patients with
chronic pain conditions such as complex regional pain
syndrome or fibromyalgia typically describe a diverse range
of somatosensory changes. This article describes how
sensory information processing can become disturbed in
fibromyalgia syndrome and complex regional pain syndrome and
how symptoms can potentially be explained by the mechanisms
that generate them.” [This is a good study, and it is to be
hoped that future studies will include myofascial TrPs. DJS]
McCabe CS, Cohen H, Blake DR. 2007.
Somaesthetic disturbances in fibromyalgia are exaggerated by
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“New perceptions included disorientation, pain, perceived
changes in temperature, limb weight or body image.
Conclusions: Our findings support the hypothesis that
motor-sensory conflict can exacerbate pain and sensory
perceptions in those with FMS to a greater extent than in Hvs.
McCain, G. A. 1999.
Treatment of fibromyalgia syndrome. J Musculoskel Pain
S., Goldenberg, D.L., Hurwitz, S. et al. 2003. Growth Hormone
and Insulin-Like Growth Factor-1 Concentrations in Women with
Fibromyalgia. J Rheumatol 30(4):809-14.
If the body mass index is taken into consideration,
there is no significant association between premenopausal FMS
patients and healthy controls with regard to average peak
growth hormone. The
authors indicate that increase in age and obesity are both
strongly linked to the GH-IGF-1 axis, and are factors that
must be considered in research concerning FMS and the GH-IGF-1
McClaflin, R. R. 1994.
Myofascial pain syndrome. Primary care strategies for early
intervention. Postgrad Med 96(2):56-59.
McConaghy, P. M., P.
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2007. Experimental sleep fragmentation impairs
attentional set-shifting in rats. Sleep
30(1):52-60. “24 hour SI (sleep interruption) produced
impairment in an attentional set shifting that is comparable
to the executive function and cognitive deficits observed in
humans with sleep apnea or after a night of experimental
McCracken, L. M. 1998.
Learning to live with the pain: acceptance of pain predicts
adjustment in persons with chronic pain. Pain
Patton NJ. 1984. Pain relief at trigger points: a
comparison of moist heat and shortwave diathermy. J
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treatments were effective in relieving the pain of sensitive
trigger points but shortwave diathermy was more effective at
decreasing the sensitivity of both sensitive and moderate
trigger points (P>0.0581). The pressure algometer was
shown to be a useful device for objectively measuring pain and
may be useful in selecting the most effective type of treatment
for trigger points.”
McCrimmon, R. J., I.
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WW. 2003. Electroconvulsive therapy in complex regional
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during 2 separate series of ETC.”
McDermott BE, Feldman MD. 2007.
Malingering in the medical setting. Psychiatr Clin
North Am. 30(4):645-662. “…the physician should
generally suspect malingering when there are tangible
incentives and when reported symptoms do not match the
physical examination or no organic basis for the physical
complaints is found.” [The authors take for granted
that their readers, psychiatrists, can diagnose ALL diseases
with standard tests and examinations. Shame on them.
Whatever happened to the oath to “Do no harm?” This
paper is food for lawyers to deny patients care.
Intelligent and trained lawyers can make mincemeat out of it
once they understand that many physicians are untrained in
diagnosis of MTPs, and there are documented changes in FM
patients that are not practical for the physician to
perform. [see: Harris RE, Clauw DJ, Scott DJ et al.
2007 and countless other references in this section. DJS]
McEwen BS, Kalia M. 2010. The role of corticosteroids and stress in chronic pain conditions. Metabolism. 59 Suppl 1:S9-15. "The relationship between corticosteroids (endogenous and exogenous) and stress is well known, as is the use of steroids as concomitant treatment in pain management during acute inflammation. In the past, steroids have not been considered the first line of treatment in pain management. In this review, we examine new scientific and clinical evidence that demonstrates the direct role that steroids play in the generation and clinical management of chronic pain."
McFadden, S. A. 1996.
Phenotypic variation in xenobiotic metabolism and adverse
environmental response: focus on sulfur-dependent
detoxification pathways. Toxicology 111(1-3):43-65.
McGreevy K, Bottros MM, Raja SN. 2011. Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy. Eur J Pain Suppl. 5(2):365-372. This paper from Johns Hopkins states: "Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon."
McIver KL, Evans C, Kraus RM et al.
2005. NO-mediated alterations in skeletal muscle nutritive
blood flow and lactate metabolism in fibromyalgia. Pain
[Dec 20 Epub Ahead of Print] “FM may be more sensitive than HC
(healthy women) to the suppressive effect of nitric oxide on
McKee, D. D. and J. N.
Chappel. 1992. Spirituality and medical practice. J Fam
McKeever TM, Lewis SA, Smit HA et al. 2005. The association of acetaminophen, aspirin, and ibuprofen with respiratory disease and lung function. Am J Respir Crit Care Med. 171(9):966-971. “Use of acetaminophen [but not aspirin or ibuprofen] is associated with an increased risk of asthma and COPD [chronic obstructive pulmonary disease], and with decreased lung function.”
McKnite AM, Perez-Munoz ME, Lu L et al. 2012. Murine gut microbiota is defined by host genetics and modulates variation of metabolic traits. PLoS One. 7(6):e39191. "The gastrointestinal tract harbors a complex and diverse microbiota that has an important role in host metabolism. Microbial diversity is influenced by a combination of environmental and host genetic factors and is associated with several polygenic diseases. In this study we combined next-generation sequencing, genetic mapping, and a set of physiological traits of the BXD mouse population to explore genetic factors that explain differences in gut microbiota and its impact on metabolic traits. Molecular profiling of the gut microbiota revealed important quantitative differences in microbial composition among BXD strains. These differences in gut microbial composition are influenced by host-genetics, which is complex and involves many loci. Linkage analysis defined Quantitative Trait Loci (QTLs) restricted to a particular taxon, branch or that influenced the variation of taxa across phyla. Gene expression within the gastrointestinal tract and sequence analysis of the parental genomes in the QTL regions uncovered candidate genes with potential to alter gut immunological profiles and impact the balance between gut microbial communities. A QTL region on Chr 4 that overlaps several interferon genes modulates the population of Bacteroides, and potentially Bacteroidetes and Firmicutes-the predominant BXD gut phyla. Irak4, a signaling molecule in the Toll-like receptor pathways is a candidate for the QTL on Chr15 that modulates Rikenellaceae, whereas Tgfb3, a cytokine modulating the barrier function of the intestine and tolerance to commensal bacteria, overlaps a QTL on Chr 12 that influence Prevotellaceae. Relationships between gut microflora, morphological and metabolic traits were uncovered, some potentially a result of common genetic sources of variation. Gut microorganisms may largely be determined by genetics."
McLean SA, Williams DA,
Harris RE et al. 2005. Momentary
relationship between cortisol secretion and
symptoms in patients with fibromyalgia.
Arthritis Rheum. 52(11):3660-3669.
“Among women with FM, pain symptoms early in
the day are associated with variations in
function of the
McLean SA, Clauw DJ. 2005.
Biomedical models of fibromyalgia.
Disabil Rehabil. 27(12):659-665. “The
tender point criteria for FM have resulted in
the common misconception among health care
professionals that this spectrum of disorders is
limited to women with high degrees of
psychological distress. A hallmark of FM
is the presence of non-nociceptive, central
pain. There is evidence of centrally
augmented pain processing, which can be detected
both with sensory testing and by more objective
measures (e.g., evoked potentials, functional
neuroimaging). An appreciation of the
neurobiological basis for these disorders, and
an understanding of some of the abnormalities of
pain processing present in patients with FM,
will hopefully provide greater understanding of
these patients. It may also serve to
decrease the level of frustration and improve
the care experience of both chronic pain
patients and physicians.”
McLean SA, Williams DA,
Clauw DJ. 2005. Fibromyalgia after motor
vehicle collision: evidence and implications.
Traffic Inj Prev. 6(2):97-104. “The
evidence that MVC trauma may trigger FM meets
established criteria for determining causality,
and has a number of important implications, both
for patient care, and for research into the
pathophysiology and treatment of these
McLeod D, Nelson K. 2013. The role of the emergency department in the acute management of chronic or recurrent pain. Australas Emerg Nurs J. 16(1):30-36. "It is evident that the ED is not the ideal setting for managing patients with chronic pain; however, it is the last resort for many who do present, and who will continue to present should their pain persist. It is time to ensure that the ED provides a consistently supportive, cohesive and integrated approach to managing patients with chronic pain syndromes."
McMahon M, Stiller
K, Trott P. 2006. The prevalence of thumb
problems in Australian physiotherapists is high:
an observational study. Aust J
Physiother. 52(4):287-292. “The
prevalence of thumb problems in Australian
physiotherapists appears to be high and can be
of sufficient severity to impact on careers.”
Myofascial trigger point therapists and other
manual therapists are greatly needed, and will
become more so as the rest of the medical world
discovers them for the treasures that they are.
The loss of even one of them is too much. There
are alternative options to TrP care that are not
as difficult on the thumbs and other parts of
the anatomy. It is to be holed that the
therapists search out their own perpetuating
factors and look into barrier release method,
frequency specific microcurrent and other
methods to effectively perform manual medicine.
McMakin CR, Oschman JL. 2013. Visceral and somatic disorders: tissue softening with frequency-specific microcurrent. J Altern Complement Med. 19(2):170-177. "Frequency-specific microcurrent (FSM) is an emerging technique for treating many health conditions. Pairs of frequencies of microampere-level electrical stimulation are applied to particular places on the skin of a patient via combinations of conductive graphite gloves, moistened towels, or gel electrode patches. A consistent finding is a profound and palpable tissue softening and warming within seconds of applying frequencies appropriate for treating particular conditions. Similar phenomena are often observed with successful acupuncture, cranial-sacral, and other energy-based techniques. This article explores possible mechanisms involved in tissue softening. In the 1970s, neuroscientist and osteopathic researcher Irvin Korr developed a "γ-loop hypothesis" to explain the persistence of increased systemic muscle tone associated with various somatic dysfunctions. This article summarizes how physiologists, neuroscientists, osteopaths, chiropractors, and fascial researchers have expanded on Korr's ideas by exploring various mechanisms by which injury or disease increase local muscle tension or systemic muscle tone. Following on Korr's hypothesis, it is suggested that most patients actually present with elevated muscle tone or tense areas due to prior traumas or other disorders, and that tissue softening indicates that FSM or other methods are affecting the cause of their pathophysiology. The authors believe this concept and the research it has led to will be of interest to a wide range of energetic, bodywork, and movement therapists."
Blasberg B. 1994. Pain-pressure threshold in
painful jaw muscles following trigger point
injection. J Orofac Pain.
8(4):384-390. “The pain-pressure threshold
was significantly lower in myofascial pain
subjects than in control subjects at all
recording sites. Pain-pressure thresholds
increased minimally in the masseter after
trigger-point injection, whereas the temporal
region was relatively unaffected.”
“Although local anesthetic injection acts
peripherally at the painful site and centrally
where pain is sustained, pain-pressure
thresholds were not dramatically increased in
myofascial pain subjects, in contrast to
controls. This suggests that in subjects
with myofascial pain, there was continued
excitability in peripheral tissues and/or
central neural areas which may have contributed
to the persistence of jaw muscle tenderness.”
McNett M, Goldenberg D, Schaefer C et al. 2011. Treatment patterns among physician specialities in the management of fibromyalgia: results of a cross-sectional study in the United States. Curr Med Res Opin. 27(3):673-683. "Fibromyalgia (FM) is characterized by persistent and widespread pain and often associated with other symptoms and comorbidities. Thus, FM patients seek care from multiple physician specialties." "Patient characteristics were similar across specialties, except with regards to Comorbidity burden. This study noted significant differences among physician specialties in HRU (healthcare resource use) and treatment patterns among medications, diagnostics, and outpatient visits. Consistent with other studies, this study did not identify a dominant strategy for FM management across physician specialties as overall per patient medical costs and subject-reported treatment satisfaction were similar. Future research to better characterize differences among physician specialties in FM management, as well as the reasons for these differences, would be useful."
McNicholas WT, Bonsignore
MR. 2007. Sleep Apnoea as an independent
risk factor for cardiovascular disease: current
evidence, basic mechanisms and research
priorities. Eur Respir J.
29(1):156-178. “Considerable evidence is
available in support of an independent
association between obstructive sleep apnoea
syndrome (OSAS) and cardiovascular disease,
which is particularly strong for systemic
arterial hypertension and growing for ischaemic
heart disease, stroke, heart failure, atrial
fibrillation and cardiac sudden death. The
pathogenesis of cardiovascular disease in OSAS
is not completely understood but likely to be
multifactorial, involving a diverse range of
mechanisms including sympathetic nervous system
overactivity, selective activation of
inflammatory molecular pathways, endothelial
dysfunction, abnormal coagulation and metabolic
dysregulation, the latter particularly involving
insulin resistance and disordered lipid
McPartland JM, Giuffrida A,
King J et al. 2005. Cannabimimetic effects of
osteopathic manipulative treatment. J Am
Osteopath Assoc. 105(6):283-291. “Healing
modalities popularly associated with changes in the
endorphin system, such as OMT [osteopathic
manipulative treatment], may actually be mediated by
the endocannabinoid system.”
McPartland JM. 2004.
Travell trigger points – molecular and osteopathic
perspectives. JAOA 104(6):244-249.
McQuay, H. 1999.
Opioids in pain management. Lancet 353(9171):2229-32.
A, Ling EA, Schubert P et al. 1998. Properties of
activated microglia and pharmacologic interference by
propentofylline. Alzheimer Dis Assoc Disord 12
This study indicates that propentofylline can down
regulate spinal glial cells.
This indicates it may be a useful medication for central
McSherry, J. A. 1989.
Cognitive impairment after head injury. Am Fam Physician
40(4):186-190. Cognitive impairment is common after head
injury, even when the injury has been minor.
GE, Cohn JN. 2003. Endothelial dysfunction and the
metabolic syndrome. Curr Diab Rep 3(1):87-92.
“The metabolic syndrome is a highly prevalent multifaceted
clinical entity produced through the interaction of genetic,
hormonal, and lifestyle factors. A distinctive
constellation of abnormalities precedes and predicts the
accelerated development of inflammation and coagulation
represent emerging risk contributors associated with obesity
and insulin resistance, central components of the metabolic
syndrome, which act in concert with traditional
abnormalities to increase cardiovascular risk.”
McVeigh JG, Finch MB,
Hurley DA et al. 2007. Tender point count and total
myalgic score in fibromyalgia: changes over a 28-day period.
Rheumatol Int. [Jul 20 Epub ahead of print].
McWhorter, J. H. and
R. B. Davis. 1998. Cherokee prescriptions for accupressure and
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Meana M, Cho R, DesMeules M. 2004. Chronic pain: the
extra burden on Canadian women. BMC Womens Health
4 Suppl 1:S17. This paper indicates that 18% of
Canadian women and 14% of Canadian men have chronic pain,
with a higher prevalence of Asians in the over 65 year age
group and a higher prevalence of Aboriginal Canadians in the
under 65 group. Of the 125,574 people represented,
age, income and education seemed to make the difference in
the percentage between men and woman. The authors stress
early identification of pain disorders and note an urgent
need for the development of patient education and
self-management programs, as the population is aging.
P, Arnold LM, Chow EH et al. 2009. Fibromyalgia
syndrome module at OMERACT 9: domain construct.
J Rheumatol. 36(10):2318-2329. [It is very
disheartening that these authors did not include the
critical step of acknowledging that co-existing
myofascial and other trigger points MUST be taken into
consideration, as many of the symptoms that they ascribe
to FM can be caused by TrPs. Recent research indicates
that every FM patients has co-existing TrPs. It
is to be hoped that this fatal flaw in this criteria
will be corrected before it encourages even more flawed
FM research with suspect conclusions.
Mease P. 2005. Fibromyalgia
syndrome: review of clinical presentation, pathogenesis,
outcome measures, and treatment. J Rheumatol
Suppl. 75:6-21. “Although the etiology of FM
is not completely understood, the syndrome is thought to
arise from influencing factors such as stress, medical
illness, and a variety of pain conditions in some, but
not all patients, in conjunction with a variety of
neurotransmitter and neuroendocrine disturbances. These
include reduced levels of biogenic amines, increased
concentrations of excitatory neurotransmitters,
including substance P, and dysregulation of the
hypothalamic-pituitary-adrenal axis. A unifying
hypothesis is that FM results from sensitization of the
central nervous system. Establishing diagnosis and
evaluating effects of therapy in patients with FM may be
difficult because of the multifaceted nature of the
syndrome and overlap with other chronically painful
conditions. Diagnostic criteria need further
refinement. The multifaceted nature of FM suggests
that multimodal individualized treatment programs may be
necessary to achieve optimal outcomes in patients with
Mease PJ, Farmer MV, Palmer RH et al. 2013. Milnacipran combined with pregabalin in fibromyalgia: a randomized, open-label study evaluating the safety and efficacy of adding milnacipran in patients with incomplete response to pregabalin. Ther Adv Musculoskelet Dis. 5(3):113-126. "In this exploratory, open-label study, adding milnacipran to pregabalin improved global status, pain, and other symptoms in patients with fibromyalgia with an incomplete response to pregabalin treatment." [See: Huskey AM, Thomas CC, Waddell JA. 2013. Occurrence of milnacipran-associated morbilliform rash and serotonin toxicity. Ann Pharmacother. 47(7-8):e32. Look at the peripheral pain generators, and treat those. DJS]
Koehl M, van der Borght K et al. 2002. Sleep restriction
alters the hypothalamic-pituitary-adrenal response to stress.
J Neuroendocrinol 14(5):397-402.
Meeus M, Goubert D, De Backer F et al. 2013. Heart rate variability in patients with fibromyalgia and patients with chronic fatigue syndrome: A systematic review. Semin Arthritis Rheum. [Jul 6 Epub ahead of print]. "FM patients show more HRV (heart rate variability) aberrances and indices of increased sympathetic activity. Increased sympathetic activity is only present in CFS patients at night. Since direct comparisons are lacking and some confounders have to be taken into account, further research is warranted. The role of pain and causality can be subject of further research, as well as therapy studies directed to reduced HRV."
Meeus M, Ickmans K, Struyf F et al. 2013. Does Acetaminophen Activate Endogenous Pain Inhibition in Chronic Fatigue Syndrome/Fibromyalgia and Rheumatoid Arthritis? A Double-Blind Randomized Controlled Cross-over Trial. Pain Physician. 16(2):E61-70. "Although enhanced temporal summation (TS) and conditioned pain modulation (CPM), as characteristic for central sensitization, has been proved to be impaired in different chronic pain populations, the exact nature is still unknown....We examined differences in TS and CPM in 2 chronic pain populations, patients with both chronic fatigue syndrome (CFS) and comorbid fibromyalgia (FM) and patients with rheumatoid arthritis (RA), and in sedentary, healthy controls, and evaluated whether activation of serotonergic descending pathways by acetaminophen improves central pain processing....After intake of acetaminophen, pain thresholds increased slightly in CFS/FM patients, and decreased in the RA and the control group. Temporal summation was reduced in the 3 groups and CPM at the shoulder was better overall, however only statistically significant for the RA group....This is the first study comparing the influence of acetaminophen on central pain processing in healthy controls and patients with CFS/FM and RA. It seems that CFS/FM patients present more central pain processing abnormalities than RA patients, and that acetaminophen may have a limited positive effect on central pain inhibition, but other contributors have to be identified and evaluated."
Meeus M, Nijs J, Hermans L et al. 2013. The role of mitochondrial dysfunctions due to oxidative and nitrosative stress in the chronic pain or chronic fatigue syndromes and fibromyalgia patients: peripheral and central mechanisms as therapeutic targets? Expert Opin Ther Targets. 17(9):1081-1089. "Introduction: Chronic fatigue syndrome (CFS) and fibromyalgia (FM) are characterized by persistent pain and fatigue. It is hypothesized that reactive oxygen species (ROS), caused by oxidative and nitrosative stress, by inhibiting mitochondrial function can be involved in muscle pain and central sensitization as typically seen in these patients. Areas covered: The current evidence regarding oxidative and nitrosative stress and mitochondrial dysfunction in CFS and FM is presented in relation to chronic widespread pain. Mitochondrial dysfunction has been shown in leukocytes of CFS patients and in muscle cells of FM patients, which could explain the muscle pain. Additionally, if mitochondrial dysfunction is also present in central neural cells, this could result in lowered ATP pools in neural cells, leading to generalized hypersensitivity and chronic widespread pain. Expert opinion: increased ROS in CFS and FM, resulting in impaired mitochondrial function and reduced ATP in muscle and neural cells, might lead to chronic widespread pain in these patients. Therefore, targeting increased ROS by antioxidants and targeting the mitochondrial biogenesis could offer a solution for the chronic pain in these patients. The role of exercise therapy in restoring mitochondrial dysfunction remains to be explored, and provides important avenues for future research in this area."
Mehl-Madrona, L. E.
1999. Comparison of ketorolac-chlorpromazine with
meperidine-promethazine for treatment of exacerbations of
chronic pain. J Am Board Fam Pract 12(3):188-94.
Mehling WE, Daubenmier J, Price CJ et al. 2013. Self-reported interoceptive awareness in primary care patients with past or current low back pain. J Pain Res. 6:403-418. "Mind-body interactions play a major role in the prognosis of chronic pain, and mind-body therapies such as meditation, yoga, Tai Chi, and Feldenkrais presumably provide benefits for pain patients. The Multidimensional Assessment of Interoceptive Awareness (MAIA) scales, designed to measure key aspects of mind-body interaction, were developed and validated with individuals practicing mind-body therapies, but have never been used in pain patients. METHODS: We administered the MAIA to primary care patients with past or current low back pain and explored differences in the performance of the MAIA scales between this and the original validation sample. We compared scale means, exploratory item cluster and confirmatory factor analyses, scale-scale correlations, and internal-consistency reliability between the two samples and explored correlations with validity measures. RESULTS: Responses were analyzed from 435 patients, of whom 40% reported current pain. Cross-sectional comparison between the two groups showed marked differences in eight aspects of interoceptive awareness. Factor and cluster analyses generally confirmed the conceptual model with its eight dimensions in a pain population. Correlations with validity measures were in the expected direction. Internal-consistency reliability was good for six of eight MAIA scales. We provided specific suggestions for their further development. CONCLUSION: Self-reported aspects of interoceptive awareness differ between primary care patients with past or current low back pain and mind-body trained individuals, suggesting further research is warranted on the question whether mind-body therapies can alter interoceptive attentional styles with pain. The MAIA may be useful in assessing changes in aspects of interoceptive awareness and in exploring the mechanism of action in trials of mind-body interventions in pain patients."
Mehling WE, Hamel KA, Acree M et al.
2005. Randomized, controlled trial of breath therapy
for patients with chronic low-back pain. Altern
Ther Health Med. 11(4):44-52. Patients with chronic low
back pain improved significantly with breath therapy.
[Although myofascial trigger points were not mentioned in
this article, it is very possible that the prevention of
paradoxical breathing, a common perpetuating factor in many
TrPs that can contribute to or cause low back pain, may have
been part of this process. DJS]
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8(Suppl):S283-92. "Primary care physicians must recognize
that the co-occurrence of risk factors for type 2 diabetes and
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aggressive risk factor intervention."
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its biological consequences suggests reasons why tobacco
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Meleger AL, Krivickas LS.
2007. Neck and back pain: musculoskeletal disorders.
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non-neurological causes of neck and back pain, including
myofascial pain and fibromyalgia.
Melikoglu M, Melikoglu MA. 2012. The prevalence of fibromyalgia in patients with Behçet's disease and its relation with disease activity. Rheumatol Int. [Sep 28 Epub ahead of print]. "FM is a common and important clinical problem that may represent an additional factor that worsens pain and physical limitations in patients with BD. The higher prevalence of FM in patients with BD seems to be affected by BD itself, rather than its severity." [This study makes an important point. Many conditions have interactive diagnoses, and we need to look for them. DJS]
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Lower cervical intramuscular injection of local anesthetic
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Mellin, G. 1998.
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presenting with a common clinical picture of pain over the upper
medial angle of the scapula were studied. The dominant
shoulder was the most commonly involved (82%). Pain
radiated to the neck and shoulder, but rarely to the arm.
Movements that stretched the levator scapulae on the affected
side aggravated symptoms.” “Anatomic dissections of 30
cadaveric shoulders showed great variability in the insertion of
the levator. A bursa was found between the scapula, the
serratus, and the levator in more than 50% of the shoulders.
This study suggests that this syndrome, leading to bursitis and
pain, may be caused by anatomic variations of the insertion of
the levator scapulae and origin of the serratus anterior.
This may explain the constant trigger point and crepitation as
well as the increased heat emission found on thermography.
Local steroid injections relieved symptoms partially in 75% of
those patients who underwent treatment.”
Menant JC, Wong A, Sturnieks DL et al. 2013. Pain and Anxiety Mediate the Relationship Between Dizziness and Falls in Older People. J Am Geriatr Soc. [Jan 25 Epub ahead of print]. "Suffering from neck and back pain and anxiety were mediators of the relationship between dizziness and falls after controlling for poor sensorimotor function and balance. Older people with dizziness might benefit from interventions targeting these mediators such as pain management and cognitive behavioral therapy." [This should include an assessment for TrPs. DJS]
Mendell, L. M., K. M.
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considered that the following were important for easing their
lives: 1. Getting a diagnosis for validating illness and helping
to focus their further search of information about explanations
and management possibilities; 2. Learning strategies to cope
with FMS by not overdoing. This implies accepting the
situation, adapting to the boundaries set by illness, and
adjusting to everyday life situations and social obligations; 3.
Support and recognition from health professionals, family and
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“...alter life goals and everyday obligations...”, while
“...maintaining a social role they considered to be
consistent with their self-image.”
It suggests that some patients with FMS may become
symptom free if their perpetuating factors can be controlled.
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Mense S. 2011. [Differences between myofascial trigger points and tender points.] Schmerz. 25(1):93-104 [German]. "The article describes and compares the characteristics of myofascial trigger points (MTrPs) of the myofascial pain syndrome and the tender points (TePs) of the fibromyalgia syndrome. Many statements are hypothetical, because not all aspects of the disorders have been clarified in solid studies. Signs and symptoms of MTrPs: (1) palpable nodule, often located close to the muscle belly, (2) often single, (3) allodynia and hyperalgesia at the MTrP, (4) referral of the MTrP pain, (5) normal pain sensitivity outside the MTrPs, (6) local twitch response, (7) local contracture in biopsy material, (8) peripheral mechanism probable. Signs and symptoms of TePs: (1) no palpable nodule, (2) location often close to the muscle attachments, (3) multiple by definition, (4) allodynia and hyperalgesia also outside the TePs, (5) enhanced pain under psychic stress, (6) unspecific histological changes in biopsy material, (7) central nervous mechanism probable. The multitude of differences speaks against a common aetiology and pathophysiology."
Mense S. 2010. How do muscle lesions such as latent and active trigger points influence central nociceptive neurons? J Musculoskel Pain. 18(4):348-353. "Spontaneous pain is mainly due to ongoing activity in nociceptive neurons in the spinal cord. Allodynia and hyperalgesia can be explained by a sensitization of central nociceptive neurons (central sensitization). One mechanism of central sensitization is the release of substance P together with glutamate from presynaptic terminals of nociceptive fibers from muscle. Other steps of sensitization are the opening of N-methyl-d-aspartate channels on postsynaptic neurons and the de novo synthesis of ion channels. The current concept of pain referral assumes that the efficacy of synaptic connections of central dorsal horn neurons can change under the influence of a nociceptive input. Thus, ineffective synaptic connections can become effective. Pain referral appears to reflect the formation of new effective central nervous connections." "Myofascial TrPs are not merely a peripheral phenomenon, the input from TrPs leads to hyperexcitability of central neurons that manifests itself in allodynia, hyperalgesia, and pain referral. These central changes are mainly based on an increase in the synaptic efficacy of central connections induced by nociceptive input." "Allodynia (pain evoked by stimuli that are not normally painful) and hyperalgesia (stronger than usual pain evoked by a painful stimulus) can be explained by a sensitization of central nociceptive neurons (central sensitization)." "One mechanism of central sensitization is the release of the neuromodulator SP together with glutamate from presynaptic terminals of nociceptive fibers from muscle." [This article explains how TrPs can cause central sensitization states such as FM, and that glial cell activation is a critical part of this process. DJS]
Mense S. 2004. Neurobiological
basis for the use of botulinum toxin in pain
therapy. J Neurol 251(Suppl 1):1/1-1/7. Botulinum
toxin interferes with the release of acetylcholine
from cholinergic nerve endings, and thus interferes
with the probable mechanism of TrP formation.
Botulinum toxin interferes with this process, thus
acting upon the pain cause, rather than just
offering symptomatic relief.
Mense S, Hoheisel U. 2004.
Central nervous sequelae of local muscle pain.
J Musculoskeletal Pain 12(3/4):101-109. This
excellent overview explains how the body and mind
work to handle acute pain, and how some of these
very changes can backfire in some patients to
promote chronic pain. There are mechanisms in
place to prevent this, but there are many variables
in both series of processes. Research in
chronic pain mechanisms, especially involving glial
cells, offer hope for answers in the near future.
Mense SS. 2004. [Functional neuroanatomy for pain
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[German] Schmerz 18(3):225-237.
Mense S. 2004. Neurobiological basis for the
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conditions, at all levels massive neuroplastic
changes take place that lead to rewiring of
connections and structural alterations in the nuclei
of the nociceptive pathways. In chronic pain
patients the neuroanatomy of pain probably differs
from that of healthy people.”
Mense S. 1999. [Neurobiological basis of muscle
pain] [German] Schmerz. 13(1):3-17. “The central
sensitization can explain the hyperalgesia and spread of
pain in patients. Chronic spontaneous muscle pain,
however, appears to be due to a lack of NO [nitric
oxide]. The final step in the transition from
acute to chronic pain involves structural changes that
perpetuate the functional changes. In rat
experiments employing nerve lesions or muscle
inflammation, such morphological changes become apparent
within a few hours after the lesion.” [Research
into the development of chronic pain has the potential
to lead to new understanding and new therapies and
medications to prevent and treat it. DJS]
Mense S. 2004. [Mechanisms of transition from
acute to chronic muscle pain] [German] Orthopade
33(5):525-532. “Norepinephrine is known to
increase cases of chronic pain, and is a stimulant of
muscle nociceptors. If BoNT inhibits the release
of these transmitters, it could be analgesic in cases of
sympathetically maintained pain including the complex
regional pain syndrome.”
Mense S. 2003. What is different
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This article calls attention to the fact that most of the
studies on pain are done on pain arising from the skin, and
yet it is deeper pains, from fascia, muscle, tendon and joint
that are more clinically significant. Research indicates
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elsewhere are different, and suggest dysfunction in descending
pain-modulating pathways could lead to the type of pain
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This excellent article brings out many fine points that
are often missed in the study of central sensitization and
muscle pain. Low pH can sensitize receptors, and a low
local pH is common in ischemia and inflammation and other
conditions and can be part of the neuroplastic changes leading
to central sensitization, causing spontaneous pain and
hyperalgesia and allodynia.
This paper also brings attention to the fact that once
central sensitization has taken place, it takes time to
normalize the body. This does not mean it is impossible
to do so, just that the patient and the clinicians must try to
restore the body balances carefully.
All perpetuating factors must be addressed and the body
given a chance to reestablish balance. There is no quick
fix. It takes time.
Mense, S., Simons, D.G.,
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may be the starting point for regional abnormal
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The frequency of spontaneously occurring micronuclei and genome-wide methylation patterns in 10 women with FM were compared. There were significant alterations in methylation patterns at 69 sites compared with those in 42 healthy controls of similar ages. "Genes associated with DM (differently methylated) sites whose function has particular relevance to FM included BDNF, NAT15, HDAC4, PPKCA, RTN1, and PRKG1."
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The interorgan interactions are already important in
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homeostasis in various body compartments and eventually result
in chronic disease through repeated borrowing of the body’s
Mira E, Martanez MP, Sanchez AI et al. 2011. When is pain related to emotional distress and daily functioning in fibromyalgia syndrome? The mediating roles of self-efficacy and sleep quality. Br J Health Psychol. 16(4):799-814. "Sleep dysfunction is importantly related to FM symptoms and deserves more attention in both research and clinical practice. Our results suggest that, in addition to the usual treatment of FM, improving sleep could optimize the current management of the syndrome." [This agrees with other research that have shown that polysomnography (sleep studies) are a necessary part of all fibromyalgia work-ups when fatigue or non-restorative sleep is part of the symptoms. If the patient is tired when they wake up, it's time to find out why. DJS]
Miranda, A. F., R. J.
Boegman, R. J. Beninger and K. Jhamandas. 1997. Protection
against quinolinic acid-mediated excitotoxicity in
nigrostriatal dopaminergic neurons by endogenous kynurenic
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Miranda LC, Parente M, Silva C et al. 2007. [Perceived
pain and weather changes in rheumatic patients.] Acta
Reumatol Port. 32(4):351-361. [Portuguese] “In our
study as well as in literature we found that a high
percentage of patients, 70, perceived that weather
conditions influenced their pain and disease.
Fibromyalgia patients seemed to be strongly influenced by
weather changes. Our study confirms that patients’
perception on the influence of climate on pain and therefore
their disease is an important clinical factor and it should
be considered when evaluating rheumatic patients.”
Miro E, Lupianez J, Hita E et al. 2011. Attentional deficits in fibromyalgia and its relationships with pain, emotional distress and sleep dysfunction complaints. Psychol Health. 3:1-16. "Cognitive complaints are common among subject with fibromyalgia (FM). Yet, few studies have been able to document these deficits with cognitive tasks. A main limitation of existing studies is that attention has been broadly defined and the tasks used to measure attention are not designed to cover all the main components of the attentional system. Research on attention has identified three primary functions of attention, known as alerting, orienting and executive functioning. This study used the attentional network test-interactions task to explore whether and which of the three attentional networks are altered in FM. Results showed that FM patients have impaired executive control (greater interference), reduced vigilance (slower overall reaction time) and greater alertness (higher reduction in errors after a warning cue). Vigilance and alertness showed several relations with depression, anxiety and sleep quality. Sleep dysfunction was a significant predictor for alertness, whereas there were no significant predictors for vigilance. These findings highlight that the treatment of sleep difficulties in FM patients may help with some of their cognitive complaints."
Mist SD, Firestone KA, Jones KD. 2013. Complementary and alternative exercise for fibromyalgia: a meta-analysis. J Pain Res. 6:247-260. "Complementary and alternative medicine includes a number of exercise modalities, such as tai chi, qigong, yoga, and a variety of lesser-known movement therapies. A meta-analysis of the current literature was conducted estimating the effect size of the different modalities, study quality and bias, and adverse events. The level of research has been moderately weak to date, but most studies report a medium-to-high effect size in pain reduction. Given the lack of adverse events, there is little risk in recommending these modalities as a critical component in a multimodal treatment plan, which is often required for fibromyalgia management."
Mist SD, Wright CL, Jones KD et al. 2011. Traditional Chinese medicine diagnoses in a sample of women with fibromyalgia. Acupunct Med. [Oct 25 Epub ahead of print]. "Three primary TCM (traditional Chinese medicine) diagnoses were found in the population (women with fibromyalgia): Qi and Blood Deficiency (46.4%, CI 33.0% to 60.36%), Qi and Blood Stagnation (26.8%, CI 15.8% to 40.3%), and Liver Qi Stagnation (19.6%, CI 10.2% to 32.4%).... It is likely that previous studies of FM were treating a heterogeneous study population where variable results might be expected. Future acupuncture studies should either control for TCM diagnosis or consider its usefulness as an inclusion/exclusion criterion."
Mitchell MD, Mannino DM, Steinke DT et al. 2011. Association of smoking and chronic pain syndromes in Kentucky women. J Pain. 12(8):892-899. "Data was analyzed on 6,092 women over 18 years of age who responded to survey questions on pain and smoking. The chronic pain syndromes included in the analysis were fibromyalgia, sciatica, chronic neck pain, chronic back pain, joint pain, chronic head pain, nerve problems, and pain all over the body. Analyses controlled for age, body mass index, and Appalachian versus non-Appalachian county of residence." "This study provides evidence of an association between chronic pain and cigarette smoking that is reduced in former smokers. PERSPECTIVE: This paper presents the association between smoking and musculoskeletal pain syndromes among Kentucky women. This finding may provide additional opportunities for intervention in patients with chronic pain."
Miyakoshi N, Shimada Y, Kasukawa Y et
al. 2007. Total dorsal ramus block for the treatment of
chronic low back pain: a preliminary study. Joint Bone
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Miyawaki S, Tanimoto Y, Araki Y et al.
2004. Relationships among nocturnal jaw muscle
acitivites, decreased esophageal pH, and sleep positions.
Am J Orthod Dentofacial Orthop 126(5):615-619.
GERD episodes that occur while sleeping on the back can
trigger jaw muscle activities, including bruxism.
Mizumura K, Murase S, Taguchi T. 2010. Animal models of myofascial trigger points. J Musculoskel Pain. 18(4):361-366. "The sensitization of muscle nociceptors to mechanical stimulation by NGF up-regulated in the muscle after LC is considered to be a mechanism for mechanical hyperalgesia after exercise. Determining whether there is any difference in expression of NGF or sensitivity of muscle nociceptors in the TrP and in other areas will be an important key for clarifying the mechanism of TrPs." This article also explains mechanisms involved in delayed onset muscle soreness.
Modell, W. J. Travell
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symptoms are associated with interruption of sleep induction and
maintenance and result in considerable economic burden and
reduction in HRQOL (health-related quality of life).”
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Mohammad A, Carey JJ, Storan E et al. 2012. High Prevalence of Fibromyalgia in Patients with HFE-related Hereditary Hemochromatosis. J Clin Gastroenterol. [Nov 21 Epub ahead of print]. "This study reveals a high prevalence of FMS (43%) among subjects with HFE-related hemochromatosis. Prospective studies are needed to better understand the risk factors for FMS in such patients."
Mohammad A, Carey JJ, Storan E et al. 2012. Prevalence of fibromyalgia among patients with chronic hepatitis C infection: relationship to viral characteristics and quality of life.
J Clin Gastroenterol. 46(5):407-412. "This study reveals a high prevalence of FMS (57%) among subjects with chronic HCV infection, one third of whom reported some degree of functional impairment. Recognition and management of this condition in such patients will help improve their quality of life."
Mohr Drewes A, Pedersen J, Reddy H
et al. 2006. Central sensitization in patients with
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Scand J Gastroenterol. 41(6):640-649. “NCCP
patients showed facilitated central pain mechanisms
(temporal summation and visceral hyperalgesia after
sensitization. [Non-cardiac chest pain is often
caused by myofascial TrPs. These patients were not
tested for scalene, pectoral, sternalis, paraspinal,
intercostal or other potential chest-pain causing TrPs.
These patients did have FMS-associated symptoms.
It is to be hoped that future studies document both TrPs
and FMS, which would considerably add to the value of
the studies. DJS]
Moldofsky H. 2010.
Rheumatic manifestations of sleep disorders. Curr
Opin Rheumatol. 22(1):59-63. “The determination of
how disordered sleep affects musculoskeletal pain, fatigue,
mood, and behavior is important in the assessment and
management of patients with rheumatic illness. The
high prevalence of obstructive sleep apnea and restless legs
syndromes requires more research to determine whether
treatments of these sleep disorders will benefit the
symptoms of rheumatic diseases.” [This lovely paper by the
master of sleep disorders is of vital importance. The
impact of unrestorative sleep cannot be overestimated, and
there are many components to sleep disturbances.
Unrestorative sleep must be considered not only as a
perpetuating factor but as an interactive diagnosis with
many other illnesses, including those associated with
musculoskeletal pain. Thank you, Dr. Moldofsky.]
Moldofsky H. 2009. The
significance of dysfunctions of the sleeping/waking brain to
the pathogenesis and treatment of fibromyalgia syndrome.
Rheum Dis Clin North Am. 35(2):275-283. “This
article reviews how functional disturbances of the
sleeping-waking brain are involved in pathogenesis of the
widespread pain, unrefreshing sleep, fatigue, and impaired
quality of life of patients who have fibromyalgia syndrome.”
One of the most common perpetuating factors for FM is lack
of restorative sleep. There are pharmaceutical and
physical agents that can help pain and fatigue while
regaining restorative sleep.
Moldofsky H. 2007. The assessment
and significance of the sleep/waking brain in patients with
chronic widespread musculoskeletal pain and fatigue
syndromes. J Musculoskel Pain 15 (Supp 13):4
item 5. [Myopain 2007 Poster] “Psychophysiological
studies demonstrate that total, partial and rapid eye
movement [REM] sleep deprivations decrease pain threshold.
Pain stimuli disturb sleep, and non-painful stimuli [e.g.
noise] that disrupt sleep [e.g. slow wave sleep] cause
unrefreshing sleep, myalgia and fatigue.” “In clinical
studies of FMS and chronic fatigue syndrome, unrefreshing
sleep is associated with frequent periodic
electroencephalogram arousals from sleep, i.e. the cyclical
alternating pattern, sleep apneas, and periodic limb
movements.” “Preliminary studies of novel treatments that
aim to facilitate restorative sleep suggest a rationale for
better management of FMS and related illnesses.” [This
information indicates that many sleep dysfunctions are
interactive with FM and other disorders.]
H. 2002. Management of sleep disorders in fibromyalgia. Rheum
Dis Clin North Am 28(2):353-65. "In summary, the
treatment of patients with FM requires a proper assessment of
the reason for the unrefreshing sleep, which is an important
component of the FM syndrome."
Moldofsky, H. 1995.
Sleep and the immune system. Int J Immunopharmacol
Moldofsky H, Harris HW, Archambault WT et al. 2011. Effects of Bedtime Very Low Dose Cyclobenzaprine on Symptoms and Sleep Physiology in Patients with Fibromyalgia Syndrome: A Double-blind Randomized Placebo-controlled Study. J Rheumatol. [Sep 1 Epub ahead of print]. "Bedtime VLD( very low dose) CBP (cyclobenzaprine) treatment improved core FM symptoms."
Moldofsky H, Inhaber NH, Guinta DR et al. 2010. Effects of Sodium Oxybate on Sleep Physiology and Sleep/Wake-related Symptoms in Patients with Fibromyalgia Syndrome: A Double-blind, Randomized, Placebo-controlled Study. J Rheumatol. [Aug 3 Epub ahead of print]. "This large cohort of patients with FM demonstrated that SXB treatment improved EEG sleep physiology and sleep-related FM symptoms." [Sodium oxybate does restore deep sleep, the area of sleep wherein neurotransmitters, hormones and other informational substances are balanced. It is most unfortunate for FM patient that the fear diversion to illegal use has caused the FDA to deny its use for FM patients. DJS]
Moldofsky, H. and A.
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Moldwin RM, Fariello JY. 2013. Myofascial trigger points of the pelvic floor; Associations with urological pain syndromes and treatment strategies including injection therapy. Curr Urol Rep Aug 14.[Epub ahead of print] "Myofascial trigger points (MTrP), or muscle 'contraction knots', of the pelvic floor may be identified in as many as 85% of patients suffering from urological, colorectal and gynecological pelvic pain syndromes; and can be responsible for some, if not all, symptoms related to these syndromes. Identification and conservative treatment of MTrPs in these populations has often been associated with impressive clinical improvements. In refractory cases, more 'aggressive' therapy with varied trigger point needling techniques, including dry needling, anesthetic injections, or botulinum toxin A injections m, may be used, in combination with conservative therapies."
Molina J, Dos Santos FH, Terreri MT et al. 2012. Sleep, stress, neurocognitive profile and health-related quality of life in adolescents with idiopathic musculoskeletal pain. Clinics (Sao Paulo). 67(10):1139-1144. Adolescents with idiopathic musculoskeletal pain did not exhibit cognitive impairments. However, adolescents with idiopathic musculoskeletal pain did experience intermediate to advanced psychological distress and lower health-related quality of life, which may increase their risk of cognitive dysfunction in the future.
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learn the mechanisms of development of metabolic syndrome, new
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Moller-Levet CS, Archer SN, Bucca G et al. 2013. Effects of insufficient sleep on circadian rhythmicity and expression amplitude of the human blood transcritome. Proc Natl Acad Sci USA. 110(12):E1132-1141. "…insufficient sleep affects the human blood transcriptome, disrupts its circadian regulation, and intensifies the effects of acute total sleep deprivation. The identified biological processes may be involved with the negative effects of sleep loss on health, and highlight the interrelatedness of sleep homeostasis, circadian rhythmicity, and metabolism." The change from 8 hours a night to 6 hours a night of sleep for even one week can cause drastic genetic effects. After one week of the 6 hour a night sleep regimen, tests of the formerly healthy subjects showed that 711 of their genes had changed, including ones that regulate the immune system.
Molnar DS, Flett G, Sadava SW et al. 2012. Perfectionism and health functioning in women with fibromyalgia. J Psychosom Res. 73(4):295-300. "Collectively, these findings clarify that overall levels of perfectionism are not elevated among women with fibromyalgia (emphasis mine DJS), but those women who are exceptionally high in levels of self-oriented perfectionism or high in socially prescribed perfectionism are particularly likely to suffer lower health functioning. These results suggest that perfectionism should be specifically assessed and targeted for intervention among women with fibromyalgia and there should be a particular emphasis on the pressure to meet perceived or actual expectations imposed on the self."
Monga, T. N., G. Tan,
H. J. Ostermann, U. Monga and M. Grabois. 1998. Sexuality and
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Monsivais D, Engebretson JC. 2012. I'm Just Not That Sick: Pain Medication and Identity in Mexican American Women with Chronic Pain. J Holist Nurs. [Jun 19 Epub ahead of print]. "To describe the beliefs and attitudes about self-identity and pain medication in a sample of Mexican American women with chronic pain living in the El Paso, Texas, area. The findings are drawn from a larger qualitative study of 15 women describing the expression and communication of chronic pain symptoms, pain-related cultural beliefs, decision making, and treatment preferences of chronic pain....A shared central theme was controlling the use of pain medications to control perceived negative associations with pain medication. The negative associations resulted in women rejecting use of medication to preserve their legitimate identity. This perception can be destructive and can lead to poor pain control....Providing patients with anticipatory guidance about common barriers to taking pain medication may allow medication use consistent with improved pain control.
Montagna, P. E.
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Montanez-Aguilera FJ, Valtuena-Gimeno N, Pecos-Martin D et al. 2010. Changes in a patient with neck pain after application of ischemic compression as a trigger point therapy. J Back Musculoskelet Rehabil. 23(2):101-104. This article describes the improvement of one patient who had neck pain for at least four months. After one session of ischemic compression on the left trapezius, range of motion increased, electromyography improved and pain decreased.
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myofascial pain syndrome must be considered in the differential
diagnosis of chronic pelvic pain. Eur J Obstet Gynecol
Reprod Biol. [Jul 21 Epub ahead of print]. “Abdominal
myofascial pain syndrome is a highly prevalent disease
associated with CPP (chronic pelvic pain), and because of this
physicians should get used to making a precise and early
diagnosis in order to avoid additional and unnecessary
investigation.” [Yet another study showing that myofascial
trigger points are extremely common and that much pain could be
saved by myofascial trigger point assessment. This
requires adequate training for care providers in the diagnosis
of TrPs, which would save enormous amounts of money and avoid
many procedures and testing in the long term. DJS]
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training based on electrical stimulation. Electromyogr Clin
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support and emotional context on pain processing and
magnetic brain responses in fibromyalgia. Arthritis
Rheum. 50(12):4035-4044. “…social support through
the presence of a significant other can influence pain
processing at the subjective-behavioral level as well as the
central nervous system level.”
Monti, D. A. and E. J.
S. Kunkel. 1998. Management of chronic pain among elderly
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M et al. 2006. Reduced brain habituation to
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Arthritis Rheum. 54(6):1995-2003. “Our findings
suggest that in FM patients, there is abnormal
information processing, which may be characterized by a
lack of inhibitory control to repetitive non-painful
somatosensory information during stimulus coding and
Montoya P, Sitges C, Garcia-Herrera M et
al. 2005. Abnormal affective modulation of somatosensory
brain processing among patients with fibromyalgia.
Psychosom Med. 67(6):957-963. “Our data suggest an
abnormal processing of nonpainful somatosensory information in
FM, especially when somatic signals are arising from the body
within an aversive stimulus context. These findings
provide further support for the use of biopsychosocial models
for understanding FM and other chronic pain states.”
[These patients were not screened for co-existing myofascial
Moore MK. 2004. Upper
crossed syndrome and its relationship to cervicogenic
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A patient with one-sided headache radiating to the eye was
found to have bilateral myofascial trigger points in the
pectoralis major, levator scapulae, upper trapezius and
supraspinatus muscles. Appropriate therapy relieved the
headache and its perpetuating factors.
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Fibromyalgia: Moderate and substantial pain intensity reduction
predicts improvement in other outcomes and substantial quality
of life gain. Pain. [Mar
25 Epub ahead of print]. “Chronic pain is associated with a
range of other problems, including disturbed sleep, depression,
anxiety, fatigue, reduced quality of life, and an inability to
work or socialize. We investigated whether good symptom control
of pain (using definitions of moderate and substantial benefit)
is associated with improvement in other symptoms. Individual
patient data from four randomized trials in fibromyalgia (2575
patients) lasting 8-14weeks were used to calculate percentage
pain reduction for each completing patient (1858), divided into
one of five groups according to pain reduction, irrespective of
treatment: substantial benefit - 50% pain reduction; moderate -
30% to <50%; minimal - 15% to <30%; marginal - 0% to <15%; worse
- <0% (increased pain intensity). We then calculated change from
baseline to end of trial for measures of fatigue, function,
sleep, depression, anxiety, ability to work, general health
status, and quality-adjusted life year (QALY) gain over a
12-month period. Substantial and moderate pain intensity
reductions were associated with statistically significant
reduction from baseline by end of trial in all measures, with
values by trial end at or approaching normative values.
Substantial pain intensity reduction resulted in 0.11 QALYs
gained, and moderate pain intensity reduction in 0.07 QALYs
gained over a 12-month period. Substantial and moderate pain
intensity reduction predicts broad beneficial outcomes and
improved quality of life that do not occur without pain relief.
Pain intensity reduction is a simple and effective predictor of
which patients should continue treatment, and which should
discontinue and try an alternative therapy."
Moore SK, Black K. 2005.
Fibromyalgia and pregnancy: what nurses need to know and
do. AWHONN Lifelines 9(3):228-235.
Moraska AF, Hickner RC, Kohrt WM et al. 2012. Changes in blood flow and cellular metabolism at a myofascial trigger point with trigger point release (ischemic compression): a proof-of-principle pilot study. Arch Phys Med Rehabil. [Sep 10 Epub ahead of print]. "Identifying physiological constituents of MTrPs following intervention is an important step toward understanding pathophysiology and resolution of myofascial pain. The present study forwards that aim by showing proof-of-concept for collection of interstitial fluid from an MTrP before and after intervention can be accomplished using microdialysis, thus providing methodological insight toward treatment mechanism and pain resolution. Of the biomarkers measured in this study, lactate may be the most relevant for detection and treatment of abnormalities in the MTrP."
Morf S, Amann-Vesti B, Forster A et al.
2005. Microcirculation abnormalities in patients with
fibromyalgia – measured by capillary microscopy and laser
fluxmetry. Arthritis Res Ther. 7(2):R209-216.
“...the peripheral blood flow in FM patients was much less than
in healthy controls but did not differ from that of SSc
[systemic scleroderma] patients. The data suggest that
functional disturbances of microcirculation are present in FM
patients and that morphological abnormalities may also influence
Moriatis Wolf J, Cameron KL, Owens BD. 2011. Impact of joint laxity and hypermobility on the musculoskeletal system. J Am Acad Orthop Surg. 19(8):463-471. "Excessive joint laxity, or hypermobility, is a common finding of clinical importance in the management of musculoskeletal conditions. Hypermobility is common in young patients and in general is associated with an increased incidence of musculoskeletal injury. Hypermobility has been implicated in ankle sprains, anterior cruciate ligament injury, shoulder instability, and osteoarthritis of the hand. Patients with hypermobility and musculoskeletal injuries often seek care for diffuse musculoskeletal pain and injuries with no specific inciting event. Orthopaedic surgeons and other healthcare providers should be aware of the underlying relationship between hypermobility and musculoskeletal injury to avoid unnecessary diagnostic tests and inappropriate management. Prolonged therapy and general conditioning are typically required, with special emphasis on improving strength and proprioception to address symptoms and prevent future injury. Orthopaedic surgeons must recognize the implications of joint mobility syndromes in the management and rehabilitation of several musculoskeletal injuries and orthopaedic disorders."
Morillas-Arques P, Rodriguez-Lopez CM, Molina-Barea R et al. 2010. Trazodone for the treatment of fibromyalgia: an open-label, 12-week study. BMC Musculoskel Disord. 10;11:204. "Trazodone markedly improved sleep quality, with large effect sizes in total PSQI (Pittsburgh Sleep Quality Index) score as well on sleep quality, sleep duration and sleep efficiency. Significant improvement, although with moderate effect sizes, were also observed in total FIQ scores, anxiety and depression scores...and pain interference with daily activities. Unexpectedly, the most frequent and severe side effect associated with trazodone in our sample was tachycardia, which was reported by 14 (21.2%) patients....In doses higher than those usually prescribed as hypnotic, the utility of trazodone in fibromyalgia management surpasses its hypnotic activity. However, the emergence of tachycardia should be closely monitored."
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patients with cancer—current problems in a pain clinic] Masui.
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patients were given some amount of pain relief by treatment of
trigger points and/or nerve block. Assessment of cancer and
other chronic pain patients for co-existing trigger points would
seem a basic part of standard adequate medical care.
Moriwaki, K. and O.
Yuge. 1999. Topographical features of cutaneous tactile
hypoesthetic and hyperesthetic abnormalities in chronic pain. Pain
Mork, H., Ashina, M.,
Bendtsen, L. et al. 2003. Experimental muscle pain and
tenderness following infusion of endogenous substances in
humans. Eur J Pain 7(2):145-53. This study
attempts to “...develop a clinically relevant model of
prolonged human myofascial pain....”
Mork P, Nilsson J, Loras H et al. 2013. Heart rate variability in fibromyalgia patients and healthy controls during non-REM and REM sleep: a case-control study. Scand J Rheumatol. [Feb 20 Epub ahead of print]. "RMSSD (root mean square successive difference), indicative of parasympathetic predominance, is attenuated in FM patients compared to HCs (healthy controls) during N2 (non-REM stage 2) sleep and REM sleep. This difference was not present for the HF component. HRV (heart rate variability) during sleep in FM patients is moderately and positively associated with sleep quality and moderately and negatively associated with neck/shoulder pain."
Mork PJ, Vasseljen O, Nilsen TI. 2010.
The association between physical exercise, body mass index, and
risk of fibromyalgia: Longitudinal data from the Norwegian HUNT
study. Arthritis Care Res (Hoboken). [Jan 29 Epub ahead
of print] “Overweight and obesity was associated with an
increased risk of FM, especially among women who also reported
low levels of physical exercise. Community based measures aimed
at reducing the incidence of FM should emphasize the importance
of regular exercise and maintenance of normal body weight.”
[Obesity is in itself a perpetuating factor of both FM and CMP,
and conditions such as hypothyroid and insulin resistance may be
some initiating factors common in some patients. There is a
substantial subset of FM patients, however, who were athletic
when they developed FM. Overweight can also be caused by
chronic pain. One must look at the whole story of each
Moroni, F. 1999.
Tryptophan metabolism and brain function: focus on kynurenine
and other indole metabolites. Eur J Pharmacol
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Morris G, Anderson G, Berk M et al. 2013. Coenzyme Q10 depletion in medical and neuropsychiatric disorders: potential repercussions and therapeutic implications. Mol Neurobiol. [Jun 13 Epub ahead of print]. "Coenzyme Q10 (CoQ10) is an antioxidant, a membrane stabilizer, and a vital cofactor in the mitochondrial electron transport chain, enabling the generation of adenosine triphosphate. It additionally regulates gene expression and apoptosis; is an essential cofactor of uncoupling proteins; and has anti-inflammatory, redox modulatory, and neuroprotective effects." "Administration of CoQ10 improves hyperalgesia and quality of life in patients with fibromyalgia. The evidence base for the effectiveness of treatment with CoQ10 may be explained via its ability to ameliorate oxidative stress and protect mitochondria."
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Clin Gastroenterol Hepatol. 2(9):761-768.
“Subjective reports of sleep quality were affected by GERD
severity, but an objective correlation between OSA and GERD
was lacking. This may suggest that GERD and OSA are common
entities that share similar risk factors, but appear not to
be causally linked.”
Persi A, Stracqualursi A et al. 2004. [The abdominal wall:
an overlooked cause of pain] G Chir
25(6-7):245-250. Abdominal wall TrPs are often overlooked
causes of pain and other symptoms often misdiagnosed as visceral
in origin. It is strongly suggested that patients be assessed
for TrPs. If they are treated and the TrPs return, perpetuating
factors may then be identified and brought under control. A
visceral-TrP loop may be the problem, but identification and
prompt treatment of abdominal and other TrPs can often avoid
“... inappropriate diagnostic tests, unsatisfactory treatment
and high costs.”
Mosca F, Persi A, Stracqualursi
A et al. 2004. [The abdominal wall: an overlooked cause of
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Pain from abdominal wall trigger points is frequently
Moseley GL, Flor H. 2012. Targeting Cortical Representations in the Treatment of Chronic Pain: A Review. Neurorehabil Neural Repair. [Feb 13 Epub ahead of print]. "Recent neuroscientific evidence has confirmed the important role of cognitive and behavioral factors in the development and treatment of chronic pain. Neuropathic and musculoskeletal pain are associated with substantial reorganization of the primary somatosensory and motor cortices as well as regions such as the anterior cingulate cortex and insula. What is more, in patients with chronic low back pain and fibromyalgia, the amount of reorganizational change increases with chronicity; in phantom limb pain and other neuropathic pain syndromes, cortical reorganization correlates with the magnitude of pain. These findings have implications for both our understanding of chronic pain and its prevention and treatment. For example, central alterations may be viewed as pain memories that modulate the processing of both noxious and non-noxious input to the somatosensory system and outputs of the motor and other response systems. The cortical plasticity that is clearly important in chronic pain states also offers potential targets for rehabilitation. The authors review the cortical changes that are associated with chronic pain and the therapeutic approaches that have been shown to normalize representational changes and decrease pain and discuss future directions to train the brain to reduce chronic pain."
Moseley GL, Gallagher L, Gallace A. 2012. Neglect-like tactile dysfunction in chronic back pain. Neurology 79(4):327-332. Patients who have chronic low back pain demonstrated a "…spatially defined disruption of tactile processing." [How much of this is due to TrP proprioception and/or latent TrP activation in the contralateral side and/or facilitated segments is not known, as patients were not assessed for TrPs. DJS]
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2006. Tai chi chih acutely decreases sympathetic nervous
system activity in older adults. J Gerontol A Biol Sci
Med Sci. 61(11):1177-1180. “TCC performance led to acute
decreases in sympathetic activity, which could not be explained
by physical activity alone.” [As FMS is associated with
up-regulation of the sympathetic nervous system, t’ai chi chuan
may be helpful for FMS. DJS]
Motley CP, Maxwell ML. 2010. Fibromyalgia: helping your patient while maintaining your sanity. Prim Care. 37(4):743-755. "In caring for the patient with fibromyalgia, the primary care provider benefits from an understanding of fibromyalgia as a distinct entity. Evidence-based diagnostic criteria for fibromyalgia can be used in all individuals who present with multiple site pain, fatigue, and poor sleep. Planning therapy for individuals with fibromyalgia often involves using both pharmacologic and nonpharmacologic treatment in the primary care setting." [The multiple site pain is generally caused by myofascial trigger points. One can't understand and treat FM without understanding the co-existing conditions that often cause it. DJs]
Mountz, J. M. , L. A.
Bradley and G. S. Alarcon. 1998. Abnormal functional activity
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J Med Sci 315(6):385-396.
Mu R, Li C, Zhu JX et al. 2013. National survey of knowledge, attitude and practice of fibromyalgia among rheumatologists in China. Int J Rheum Dis. 16(3):258-263. "The awareness and perception of FM are still low among Chinese rheumatologists. Continuing medical education on FM is needed for improving the quality of health care in China." [Much the same could be said of all countries. DJS]
HH, Donaldson CC, Nelson DV, Layman M. 2001. Treatment
of fibromyalgia incorporating EEG-Driven stimulation: A
clinical outcomes study. J Clin Psychol
57(7):933-52. "Electroencephalograph (EEG)-driven
stimulation or EDS. Patients were initially treated with EDS
until they reported noticeable improvements in mental clarity,
mood, and sleep. Self-reported pain, then, having
changed from vaguely diffuse to more specifically localized,
was treated with very modest amounts of physically oriented
HW, Klapka N, Hermanns S. 2002. Glial scarring as
impediment for axon regeneration in the CNS-getting across.
Glia (Suppl 1):S91 [Abstract].
Muller KG, Richter A, Bieber C
et al. 2004. [no title given]. Z Arztl Fortbild
Qualitatssich 98(2):95-100. [German]. “Conditions
affecting the musculoskeletal system are the cause of
approximately 25% of absenteeism from work...The
physician-patient relationship is burdened with resignation
and frustration on both sides....The patient’s active
involvement in the decision making process is expected to
improve the physician-patient relationship. One aspect
of this shared decision- making process is the evaluation
and possibly modification of treatment decisions.”
Muller KG, Richter A, Bieber C et al. 2004.
The process of shared decision making in chronic pain patients:
Evaluation and modification of treatment decisions. Z
Arztl Fortbild Qualitatssich 98(2):95-100. [German].
Muller W, Fiebich BL, Stratz T. 2006.
New treatment options using 5-HT3 receptor antagonists in
rheumatic diseases. Curr Top Med Chem.
6(18):2035-2042. “Clinical trials have provided evidence of
pain reduction in a subgroup of fibromyalgia syndrome and,
moreover, have demonstrated that tropisetron injected locally
for insertion tendinoses and myofascial syndromes with
associated trigger points leads to an alleviation of pain that
is comparable to injections with the combination of
corticosteroids and local anesthetics.”
W, J Kelemen and T Stratz. 1998. The spinal factors in the
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Muller-Ehrenberg H, Thorwesten L.
2007. Frequency and importance of trigger points in
the case of sports-related shoulder pain. J
Musculoskel Pain 15 (Supp 13):33 item 55. [Myopain
2007 Poster] “Trigger points [TrPs] can often be diagnosed
when patients complain about sports-related shoulder pain,
and they contribute considerably to the symptoms.
Including the examination for TrP will therefore broaden the
understanding of the cause of shoulder pain.”
Muller-Ehrenberg H, Thorwesten L. 2007.
Improvement of sports-related shoulder pain after treatment of
trigger points using focused extracorporeal shock wave therapy
regarding static and dynamic force development, pain relief and
sensomotoric performance. J Musculoskel Pain 15
(Supp 13):33 item 56. [Myopain 2007 Poster] “The
treatment of trigger points using focused ESWT (extracorporeal
shock wave therapy) significantly improves the pain symptoms as
well as the performance of athletes suffering from acute or
chronic shoulder pain.” This study used piezoelectric shock
waves, with significant reduction in pain and return to
Muls, E and G
Vansant. 1999. Clinical approaches to healthier diet
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Munguia-Izquierdo D, Legaz-Arrese A. 2007. Exercise in warm
water decreases pain and improves cognitive function in
middle-aged women with fibromyalgia. Clin Exp Rheumatol.
25(6):823-830. “An exercise therapy three times per week
for 16 weeks in a warm-water pool is an adequate treatment to
decrease the pain and severity of FM well as to improve
cognitive function in previously unfit women with FM and
heightened painful symptomatology.”
Mur, E., A. Drexler,
J. Gruber, F. Hartig and V. Gunther. 1999. [No title
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Muratani T, Doi Y, Nishimura W et al.
2005. Preemptive analgesia by zaltoprofen that
inhibits bradykinin action and cyclooxygenase in a
post-operative pain model. Neurosci Res.
51(4):427-433. “The post-operative pain state results
from a barrage of primary afferent inputs exposed to
products of tissue damage such as bradykinin and
prostaglandins and the central sensitization by the
continuing inputs. This provides the rationale for
preemptive analgesia, whereby the blockade of primary
afferent inputs prior to injury may result in a reduction of
post-operative pain. These results suggest that
zaltoprofen produces the preemptive analgesic effect
peripherally by clocking the B(2) pathway.”
RA, Stuginski-Barbosa J, Moraes NP et al. 2009.
Toothache referred from auriculotemporal neuralgia: case
report. Int Endod J. 42(9):845-851. This is yet
another case report demonstrating that TrPs can cause
toothache that does not originate from the tooth, but is
instead a referral pain from the TrPs.
2002. Brain injury as a result of whiplash injury: a
controversy. J Whiplash and Rel Dis 1(1):77-84.
“Despite disagreements, it is clear from the literature that
brain injury can result from whiplash.”
Murphy SL, Phillips K, Williams DA et al. 2012. The role of the central nervous system in osteoarthritis pain and implications for rehabilitation. Curr Rheumatol Rep. [Aug 10 Epub ahead of print]. It has been known for some time that central nervous system (CNS) pain amplification is present in some individuals with osteoarthritis; the implications of this involvement, however, are just starting to be realized....This review article focuses on current literature describing CNS amplification in osteoarthritis by discussing peripheral sensitization, central sensitization, and central augmentation, and the clinical manifestation of central augmentation referred to as centralized pain, and offers considerations for rehabilitation treatment and future directions for research.
Murray B, Yashar BM, Uhlmann WR et al. 2013. Ehlers-Danlos syndrome, hypermobility type: A characterization of the patients' lived experience. Am J Med Genet A. 161(12):2981-2988. "Hypermobility type Ehlers-Danlos syndrome (EDS-HT) is an inherited connective tissue disorder clinically diagnosed by the presence of significant joint hypermobility and associated skin manifestations. This article presents a large-scale study that reports the lived experience of EDS-HT patients, the broad range of symptoms that individuals with EDS-HT experience, and the impact these symptoms have on daily functioning. A 237-item online survey, including validated questions regarding pain and depression, was developed. Four hundred sixty-six (466) adults (90% female, 52% college or higher degree) with a self-reported diagnosis of EDS-HT made in a clinic or hospital were included. The most frequently reported symptoms were joint pain (99%), hypermobility (99%), and limb pain (91%). They also reported a high frequency of other conditions including chronic fatigue (82%), anxiety (73%), depression (69%), and fibromyalgia (42%). Forty-six percent of respondents reported constant pain often described as aching and tiring/exhausting. Despite multiple interventions and therapies, many individuals (53%) indicated that their diagnosis negatively affected their ability to work or attend school. Our results show that individuals with EDS-HT can experience a wide array of symptoms and co-morbid conditions. The degree of constant pain and disability experienced by the majority of EDS-HT respondents is striking and illustrates the impact this disorder has on quality of life as well as the clinical challenges inherent in managing this complex connective tissue disorder."
Muscolino JE. 2013. Abdominal wall triggerpoint case study. J Bodyw Mov Ther 17(2):151-156. "When myofascial pain syndrome is responsible for a patient's condition and is not recognized by the patient's medical advisors, the patient may be put through a plethora of testing procedures to find the cause of the patient's pain, and prescribed medications in an effort to treat the patient's symptoms, The case review presented here involves a patient with severe anterior abdominal pain, with a history of Crohn's disease, who experienced a long and difficult medical process before a diagnosis of myofascial pain syndrome was made."
Mustian KM, Katula JA, Zhao H. 2006.
A pilot study to assess the influence of tai chi chuan on
functional capacity among breast cancer survivors.
J Support Oncol. 4(3):139-145. “The TCC (t’ai chi
chuan) group demonstrated significant improvement in
functional capacity (specifically aerobic capacity, muscular
strength, and flexibility) whereas the PST group showed
significant improvement in flexibility only. These
data suggest that TCC may be an efficacious intervention for
enhancing functional capacity among breast cancer
Muzammil S, Cooper HC. 2011. Acute pancreatitis and fibromyalgia: Cytokine link. N Am J Med Sci. 3(4):206-208. [Case Report] "There is a known increase in levels of cytokines in patients with fibromyalgia. Part of the pathophysiology of acute pancreatitis is related to raised cytokines and immune deregulations. We hypothesize that elevated levels of cytokines in fibromyalgia has led to acute pancreatitis in our patient. Further epidemiological research on the incidence of pancreatitis in cytokine mediated conditions such as fibromyalgia is required."
Myburgh C, Lauridsen HH, Hartvigsen J. 2010. Standardized manual palpation of myofascial trigger points in relation to neck/shoulder pain; the influence of clinical experience on inter-examiner reproducibility. Man Ther. [Aug 31 Epub ahead of print]. "Identification of clinically relevant TrPs of the upper trapezius musculature is reproducible when performed by two experienced clinicians...." [This study conforms what has been found before. Myofascial TrP diagnosis by palpation is repeatable with trained, experienced care providers. It takes a concerted effort to get that experience. DJS]
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et al. 1999. Proprioception and neuromuscular control
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34(4):362-367. “Fatigue of the internal and external
rotators of the shoulder decreased proprioception of the
shoulder, while having no significant effect on
Myers T. 2007. Treatment approaches for
three shoulder “tethers.” J Bodywork Movement Ther
1(11):3-8. This excellent article offers an in depth look at
three common “sticking points” in the shoulder complex (subclavious,
pectoralis minor, and teres minor) and how to treat them.
T, Morishima S, Cover T.L. et al. 2003. Recovery from
lactacidosis-induced glial cell swelling with aid of exogenous
anion channels. Glia 41(3):247-59. Cerebral edema
associated with lactacidosis or head trauma may be associated
with swelling in astrocytes, and may be treated by introducing
anion channel activity. [This may be relevant to some of the
cerebral swelling and cognitive dysfunction noted in
Nacir B, Genc H, Duyur Cakit B et al. 2012. Evaluation of Upper Extremity Nerve Conduction Velocities and the Relationship between Fibromyalgia and Carpal Tunnel Syndrome. Arch Med Res. [Jul 24 Epub ahead of print]. "We determined an increased rate of CTS (carpal tunnel syndrome) and decreased NCV (nerve conduction velocities) in the upper extremities in patients with FS. We should consider that complaints of paresthesia and pain in hands, increasing especially at night, observed in FS may mask that CTS can be an associated illness."
SF, Feinberg JH, Reisman S, Stitik TP, DePrince ML, Hengehold
D, Weingand K. 2001. Effect of topical heat on
electromyographic power density spectrum in subjects with
myofascial pain and normal controls: a pilot study. Am J
Phys Med Rehabil Nov;80(11):809-15. Myofascial pain
patients responded differently to exercise and heat challenge.
This may indicate a difference in muscle physiology.
Naja ZM, Al-Tannir MA, Zeidan A et al.
2007. Nerve stimulator-guided repetitive paravertebral
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for chronic MTPs resistant to standard treatments]
Nakagawa T, Kaneko S. 2010. Spinal Astrocytes as Therapeutic Targets for Pathological Pain. J Pharmacol Sci. [Nov 11 Epub ahead of print]. "Development of next-generation analgesics requires a better understanding of the molecular and cellular mechanisms underlying pathological pain. Accumulating evidence suggests that the activation of glia contributes to the central sensitization of pain signaling in the spinal cord. The role of microglia in pathological pain has been well documented, while that of astrocytes still remains unclear. After peripheral nerve inflammation or injury, spinal microglia are initially activated and subsequently sustained activation of astrocytes is precipitated, which are implicated in the induction and maintenance of pathological pain. Astrocytic activation is caused by the production of diffusible factors from primary afferent neurons (neuron-to-astrocyte signals) and activated microglia (microglia-to-astrocyte signals). Although astrocyte-to-neuron signals implicated in pathological pain is poorly understood, activated astrocytes, as well as microglia, produce proinflammatory cytokines and chemokines, which lead to adaptation of the dorsal horn neurons. Furthermore, it has been suggested that glial glutamate transporters in the spinal astrocytes are down-regulated in pathological pain and that up-regulation or functional enhancement of these transporters prevents pathological pain. This review will briefly discuss novel findings on the role of spinal astrocytes in pathological pain and their potential as a therapeutic target for novel analgesics."
Naliboff BD, Wu SM, Schieffer B et al. 2010. A Randomized Trial of Two Prescription Strategies for Opioid Treatment of Chronic Nonmalignant Pain. J Pain. [Nov 24 Epub ahead of print]. "The results of this study demonstrate that even in carefully selected patients there is a significant risk of problematic opioid misuse. Although in general there were no statistically significant differences in the primary outcomes between groups, the escalating dose strategy did lead to small improvements in self-reported acute relief from medications without an increase in opioid misuse, compared to the stable dose strategy."
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Skijarevski V. 2009. Predictors of premature
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the conventional belief that premature treatment
discontinuation is primarily related to adverse events, our
findings suggest lack of therapeutic response also plays a
significant role in patient attrition. This research
highlights the importance of systematic monitoring of
therapeutic response in clinical practice as a measure to
prevent patients’ discontinuation from pharmacological
Napadow V, Edwards RR, Cahalan CM et al. 2012. Evoked Pain Analgesia in Chronic Pelvic Pain Patients Using Respiratory-Gated Auricular Vagal Afferent Nerve Stimulation. Pain Med. [May 8 Epub ahead of print]. "Objective: Previous vagus nerve stimulation (VNS) studies have demonstrated antinociceptive effects, and recent noninvasive approaches, termed transcutaneous-vagus nerve stimulation (t-VNS), have utilized stimulation of the auricular branch of the vagus nerve in the ear. The dorsal medullary vagal system operates in tune with respiration, and we propose that supplying vagal afferent stimulation gated to the exhalation phase of respiration can optimize t-VNS.. RAVANS (respiratory-gated auricular vagal afferent nerve stimulation) produced promising antinociceptive effects (in CPP patients) for quantitative sensory testing (QST) outcomes reflective of the noted hyperalgesia and central sensitization in this patient population."
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et al. 2010. Intrinsic brain connectivity in fibromyalgia is
associated with chronic pain intensity. Arthritis Rheum.
[Apr 6 Epub ahead of print]. “Our findings indicated that
resting brain activity within multiple networks is
associated with spontaneous clinical pain in FM. These
findings may also have broader implications for how
subjective experiences such as pain from a complex interplay
amongst multiple brain networks.” [As synaptic junctions are
under the control of neurotransmitters, and that many
neurotransmitters may be dysregulated in central
sensitization states such as FM, this is a logical finding.
Naschitz JE, Rozenbaum M, Fields MC et
al. 2005. Cardiovascular reactivity in fibromyalgia:
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32(2):335-339. “Patients with FM represent a
heterogenous group with respect to their pattern of
Naschitz JE, Rosner I, Rozenbaum M et al. 2003. The head-up tilt
test with haemodynamic instability score in diagnosing chronic
fatigue syndrome. QJM 96(2):133-142. The
particular dysautonomia in CFS is different from that
occurring in fibromyalgia and other illnesses, and this
difference can be measured with objective testing.
JE, Rozenbaum M, Rosner I, Sabo E, Priselac RM, Shaviv N,
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Somatosensory precision in speech production. Curr
Biol. 16(19):1918-1923. This study indicates that somatosensory
feedback is necessary for vocal precision. [This has
implications for TrP and associated proprioception
involvement in speech dysfunction. DJS.]
Natelson BH. 2013. Brain dysfunction as one cause of CFS symptoms including difficulty with attention and concentration. Front Physiol. 4:109. "We have been able to reduce substantially patient pool heterogeneity by identifying phenotypic markers that allow the researcher to stratify chronic fatigue syndrome (CFS) patients into subgroups. To date, we have shown that stratifying based on the presence or absence of comorbid psychiatric diagnosis leads to a group with evidence of neurological dysfunction across a number of spheres. We have also found that stratifying based on the presence or absence of comorbid fibromyalgia leads to information that would not have been found on analyzing the entire, unstratified patient group. Objective evidence of orthostatic intolerance (OI) may be another important variable for stratification and may define a group with episodic cerebral hypoxia leading to symptoms. We hope that this review will encourage other researchers to collect data on discrete phenotypes in CFS to allow this work to continue more broadly. Finding subgroups of CFS suggests different underlying pathophysiological processes responsible for the symptoms seen. Understanding those processes is the first step toward developing discrete treatments for each."
M, Araque A. 2008. Endocannabinoids mediate neuron-astrocyte
communication. Neuron. 57(6):883-893. This
study has “...indicated the existence of an endocannabinoid-mediated
neuron-astrocyte communication, revealing that astrocytes (a
type of glial cell) are targets of cannabinoids.” These
glial cells might participate in cannabinoid addiction, but
might also be a “...bridge for nonsynaptic interneuronal
communication.” As aggravated glial cells have been
implicated in central sensitization, a dysfunction in the
endocannabinoid system may be part of the problems in the
cognitive deficits found in FM, as has been indicated by
other research. DJS]
Navarro RP. 2009. Contemporary
management strategies for fibromyalgia. Am J Manag Care.
15(7 Suppl):S197-218. “A roundtable meeting that
comprised clinical, patient advocacy, and managed care
experts discussed issues regarding the diagnosis and
management of fibromyalgia. The panel agreed that
earlier diagnosis and treatment, additional education for
the medical community, and appropriate management by health
plans, including patient access to US Food and Drug
Administration-approved fibromyalgia medications, are
needed. In addition, physicians, payers, and patient
advocates must work to improve clinical, economic, and
quality-of-life outcomes for fibromyalgia patients.
Finally, treatment and diagnostic guidelines must be updated
as advances in disease management are made (including
approvals of three new pharmacologic agents), and
development of a therapeutic category for “fibromyalgia” on
payer formularies is needed.” [This is a fine paper,
and it must be done for myofascial pain as well, as these
two diagnoses often occur in the same patients. DJS]
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Nazarian A, Tenayuca JM, Almasarweh F et al. 2013. Sex differences in formalin-evoked primary afferent release of substance P. Eur J Pain. [Jun 10 Epub ahead of print]. "Sex differences in pain have been well documented; however, the mechanisms involved remain to be elucidated. The present study examined whether sex differences exist in the functioning of primary afferent fibres by assessing formalin-evoked release of substance P by way of neurokinin 1 receptor (NK1r) internalization. The study also investigated whether the observed effects would be oestradiol-sensitive….These findings suggest that oestradiol mediates sex differences in formalin-evoked substance P release, which may contribute to a differential development of central sensitization and pain behaviors in males and females."
Nebel MB, Gracely RH. 2009. Neuroimaging of
fibromyalgia. Rheum Dis Clin North Am.
35(2):313-327. “Using a wide array of techniques,
these studies have found differences in opioid receptor
binding, in the concentration of metabolites associated with
neural processing in pain-related regions, in functional
brain networks, and in regional brain volume and white
matter tracks. A common theme of all of these methods
is that they provide information that may be pertinent to
the otherwise unobservable and poorly treated symptoms of
persistent widespread chronic pain.” [There may be many
ways in which pain is uncontrolled in FM. FM is real, even
though there are no easy and widely available tests for it.
It is to be hoped that those doctors and other professionals
who “don’t believe in FM,” as if it were on par with a
horoscope, will read good studies such as this and become
educated. FM is not a faith-based belief, it is medical and
scientific fact. DJS]
Neblett R, Cohen H, Choi Y et al. 2013. The Central Sensitization Inventory (CSI): Establishing Clinically-Significant Values for Identifying Central Sensitivity Syndromes in an Outpatient Chronic Pain Sample. J Pain. [Mar 9 Epub ahead of print]. "Central sensitization (CS) is a proposed physiological phenomenon in which central nervous system neurons become hyperexcitable, resulting in hypersensitivity to both noxious and non-noxious stimuli. The term central sensitivity syndrome (CSS) describes a group of medically indistinct (or nonspecific) disorders, such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome, for which CS may be a common etiology. In a previous study, the central sensitization inventory (CSI) was introduced as a screening instrument for clinicians to help identify patients with a CSS…. The CSI is a new self-report screening instrument to help identify patients with CSSs, including fibromyalgia. The present study investigated CSI scores in a heterogeneous pain population, with a large percentage of CSSs, and a normative nonclinical sample to determine a clinically relevant cutoff value."
Nedergaard M. 2013. Neuroscience. Garbage truck of the grain. Science 340 (6140):1529-1530. [This article focuses predominantly on neurodegenerative diseases, but the effect of the proposed glial cell network in clearing excess interstitial fluid from the brain is, I believe, very relevant to patients with fibromyalgia. During or after the process of neurodegeneration, abnormal proteins can be difficult to process and remove from the brain. This is the case in Alzheimer's disease, wherein tau and beta-amyloid can accumulate. Cytosolic proteins may be released into the brain's interstitial space, indicating that there may be a pathway for extracellular disposal of these neurotoxic wastes. (This may also be a possibility for quinolinic acid, which can be produced instead of serotonin in the tryptophan kynurenine alternative metabolic pathway found in some fibromyalgia patients.) There are aquaporin 4 (AQP4) channels on the vascular endfeet of astrocytes, a type of glial cell, that facilitate the flow from around the outsides of the arteries to the interstitial space. The cerebrospinal fluid exchanges with the interstitial fluid, driving waste products from the arteries to the veins. The interstitial fluid flows around the veins to the lymphatic system in the neck area, and the material in the interstitial fluid eventually finds its way into the lymph system. Up to 80% of the large proteins and soluble wastes and metabolic by-products in the brain are removed by this system of glial cells and lymph vessels working through the interstitial space. Dr. Nedergaard calls this system in the brain the "glymphatic system". When AQP4 is dysfunctional or inappropriately located, as can occur after trauma or stroke (or perhaps exposure to quinolinic acid if the kynurenine metabolic pathway is in use) this can result in excess proteins, solutes and perhaps fluid accumulation. Perhaps defects in the glymphatic system could be part of the cause of fibrofog and cerebral fluid accumulation in fibromyalgia patients. Excess interstitial fluid in the body has been observed in some fibromyalgia and insulin-resistant patients. It is extremely difficult to rid the interstitial space of accumulated fluid. The research being done by Dr. Nedergaard and others may offer insight and hope to some of us who have diffuse interstitial swelling and confusional states. DJS]
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28-year-old woman experienced respiratory depression and
hemiplegia after the injection of a superficial trapezius
trigger point. The patient required emergency tracheal
intubation for ventilatory support. Computed tomography of
her head revealed pneumocephalus. She recovered fully over
the course of 24 hours. Intrathecal injection during a
trigger-point injection is a previously unreported complication
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"Tension-type headache (TTH) and fibromyalgia syndrome (FM) are worldwide seen chronic pain syndromes of unknown etiology. Despite the growing body of data on pathophysiology and generation mechanisms of pain, our knowledge on pain....These results (from Turkey) indicated that FM and TTH patients revealed higher oxidative stress index and lower total nitrite levels than healthy controls. We conclude that oxidative stress may have a role in the pathophysiological mechanisms of TTH and FM, although whether it is the cause or the consequence is not clear."
Neziri AY, Limacher A, Juni P et al. 2013. Ranking of Tests for Pain Hypersensitivity According to Their Discriminative Ability in Chronic Neck Pain. Reg Anesth Pain Med. 38(4):308-320. "Quantitative sensory testing (QST) is widely used to investigate peripheral and central sensitization. However, the comparative performance of different QST for diagnostic or prognostic purposes is unclear. We explored the discriminative ability of different quantitative sensory tests in distinguishing between patients with chronic neck pain and pain-free control subjects and ranked these tests according to the extent of their association with pain hypersensitivity….Pressure stimulation at the site of the most severe pain and parameters of electrical stimulation were the most appropriate QST to distinguish between patients with chronic neck pain and asymptomatic control subjects. These findings may be used to select the tests in future diagnostic and longitudinal prognostic studies on patients with neck pain and to optimize the assessment of localized and spreading sensitization in chronic pain patients."
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Ther 22(9):586-93. Calcium and magnesium supplements may
be indicated as an adjunctive treatment of fibromyalgia.
Nguyen BM. 2013. Myofascial trigger point falls in the elderly, idiopathic knee pain and osteoarthritis: An alternative concept. Med Hypotheses. [April 5 Epub ahead of print]. "Knee alignment and associated pathological abnormal forces transmitted through the knee is thought to provoke joint protective mechanism in reflex arthrogenic muscle inhibition (AMI) and the start of the idiopathic knee osteoarthritic process. The current prevailing hypothesis is AMI initiates quadriceps muscle weakness, cause aberrant loading of the knee joint and focal cartilage destruction. This paper investigates for evidence in the literature if this conceptual framework is consistent with the clinical evidence, and if there is an alternative explanation to AMI hypothesis for the pathogenesis of idiopathic knee osteoarthritis. One crucial question yet to be answered by the AMI hypothesis is; where are the initial aggravating factors of reflex AMI emanate from? AMI hypothesis relies on joint damage and changes in joint homeostasis to provoke a reflex arthrogenous response which can be found late in the development of knee OA. Myofascial trigger point (MTrP) hypothesis only relies on muscle tightness, pain and weakness to detect early pathological neuromuscular changes including knee instability and falls in the elderly. AMI is implicated in the knee OA pathological process but much later on when there are changes in joint homeostasis and joint cartilage damage have occurred. Falls in the elderly are a result of early pathological neuromuscular changes. The MTrP hypothesis is more sensitive and advanced in the early detection of neuromuscular impairment and pathological changes, allowing early intervention, prevention of falls in the elderly and idiopathic knee osteoarthritis." [Researchers are discovering that bones follow muscles, and that it is the muscle contracture by TrPs causing the wear and tear on bony areas of joints that leads to osteoarthritis. DJS]
Nguyen BM. 2010. Trigger point therapy and plantar heel pain: A case report. Foot (Edinb). [Oct 26 Epub ahead of print]. Myofascial trigger points are a common cause of the condition often called plantar fasciitis. Trigger point therapy for plantar fasciitis has been neglected in medicine. [We can not afford to describe a set of symptoms and call that a diagnosis. We must look at the cause and treat the cause. DJS]
Nguyen MH, Kruse A. 2012. A randomized controlled trial of Tai chi for balance, sleep quality and cognitive performance in elderly Vietnamese. Clin Interv Aging. 7:185-90. "Tai chi is beneficial to improve balance, sleep quality, and cognitive performance of the elderly."
Nguyen RH, Ecklund AM, Maclehose RF et al. 2012. Co-morbid pain conditions and feelings of invalidation and isolation among women with vulvodynia. Psychol Health Med. [Feb 13 Epub ahead of print]. "Having a co-morbid condition with vulvodynia, as well as having an increasing number of co-morbid conditions with vulvodynia, was significantly associated with the presence of feeling both invalidated and isolated. Chronic fatigue syndrome was the co-morbidity most strongly associated with feelings invalidation and isolation. One or more co-morbid pain conditions in addition to vulvodynia were significantly associated with psychosocial wellbeing.... future studies should explore the utility of promoting validation of women's pain conditions and reducing social isolation for women with chronic pain. [It is most unfortunate that the co-existing condition most interactive with and often causative of vulvodynia, chronic myofascial pain, was not considered among these conditions. DJS]
Nguyen RH, Veasley C, Smolenski D. 2013. Latent class analysis of comorbidity patterns among women with generalized and localized vulvodynia: preliminary findings. J Pain Res. 6:303-309. "The pattern and extent of clustering of comorbid pain conditions with vulvodynia is largely unknown. However, elucidating such patterns may improve our understanding of the underlying mechanisms involved in these common causes of chronic pain….This novel work provides insight into potential shared mechanisms of vulvodynia by describing that a prominent comorbidity pattern involves having both irritable bowel syndrome and fibromyalgia. In addition, the prevalence of a multiple comorbidity class pattern increases with increasing severity of vulvar pain." [Until the medical world understands that many symptoms often labeled generalized and localized vulvodynia or fibromyalgia are actually due to or sustained by myofascial trigger points, and that those TrPs are the critical generating co-existing condition, researchers are going to miss the critical (trigger) point. DJS]
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passive coping contributed to a dysfunctional cycle
characterized by heightened pain and depressive symptomatology,
leading to greater fatigue. The continued effort to
develop effective interventions to reduce maladaptive coping
efforts in FMS is warranted by these findings.”
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E.G., Schuman C.E. et al. 2002. The contribution of
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fatigue in fibromyalgia. Pain 100(3):271-9. The
study indicates that the fatigue of fibromyalgia is due to
poor sleep quality. Lack
of restorative sleep is a perpetuating factor that must be
addressed to alleviate patient’s fatigue.
Nicolaidis C. 2011. Police Officer, Deal-Maker, or Health Care Provider? Moving to a Patient-Centered Framework for Chronic Opioid Management. Pain Med. [May 3 Epub ahead of print].
"How we frame our thoughts about chronic opioid therapy greatly influences our ability to practice patient-centered care. Even providers who strive to be nonjudgmental may approach clinical decision-making about opioids by considering if the pain is real or they can trust the patient. Not only does this framework potentially lead to poor or unshared decision-making, it likely adds to provider and patient discomfort by placing the provider in the position of a police officer or a judge. Similarly, providers often find themselves making deals with patients using a positional bargaining approach. Even if a compromise is reached, this framework can potentially inadvertently weaken the therapeutic relationship by encouraging the idea that the patient and provider have opposing goals. Reframing the issue can allow the provider to be in a more therapeutic role. As recommended in the American Pain Society/American Academy of Pain Medicine guidelines, providers should decide whether the benefits of opioid therapy are likely to outweigh the harms for a specific patient (or sometimes, for society) at a specific time. This article discusses how providers can use a benefit-to-harm framework to make and communicate decisions about the initiation, continuation, and discontinuation of opioids for managing chronic nonmalignant pain. Such an approach focuses decisions and discussions on judging the treatment, not the patient. It allows the provider and the patient to ally together and make shared decisions regarding a common goal. Moving to a risk-benefit framework may allow providers to provide more patient-centered care, while also increasing provider and patient comfort with adequately monitoring for harm."
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electrostimulation delivered within a myofascial trigger point (MTP)
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are dysfunctional in FM patients, researchers used a needle
electrode or pressure to stimulate MTPs. Both stimulations
produced a higher pain response than normal controls, with
“significantly enhanced somatosensory activity (SI, SII,
inferior pareital, mid insula) and limbic (anterior insula)
activity and suppressed right dorsal hippocampal activity in
patients compared with controls.” The results show that the
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21(3):465-480. “In FMS there is strong scientific support
for the statement that the biological part of the syndrome is a
longstanding or permanent change in the function of the
nociceptive nervous system that can be equated with a disease.”
“FMS may be the far end of a continuum that starts with chronic
localized/regional musculoskeletal pain and ends with widespread
chronic disabling pain.”
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fibromyalgia. Curr Pain Headache Rep 5(4):330-7. The
opinion that fibromyalgia syndrome (FMS) is a psychiatric
disorder or can be caused by stress or abuse is unproven and
can be of potential harm to patients. Care providers should be
aware of "possible undue influences on medical
opinion by agencies providing health care and research
Nijs J, Crombez G, Meeus M et al. 2012. Pain in patients with chronic fatigue syndrome: time for specific pain treatment? Pain Physician. 15(5):E677-686. "Besides chronic fatigue, patients with chronic fatigue syndrome (CFS) have debilitating widespread pain. Yet pain from CFS is often ignored by clinicians and researchers....From the available literature....Pain seems to be one out of many symptoms related to central sensitization from CFS. This idea is supported by the findings of generalized hyperalgesia (including widespread increased responsiveness to painful stimuli) and dysfunctional endogenous analgesia in response to noxious thermal stimuli. Pain catastrophizing and depression partly account for pain from CFS. Pain increases during exercise is probably due to the lack of endogenous analgesia and activation of several genes in response to exercise in CFS. [This study was simply a review of other studies, all of which totally ignored the possibility that CFS patients could have pain from co-existing myofascial trigger points or other local sources. It is a fine example of how bad research can lead to further bad research. DJS]
Nijs J, Daenen L, Cras P et al. 2011. Nociception Affects Motor Output: A Review on Sensory-motor Interaction with Focus on Clinical Implications. Clin J Pain. [Jun 27 Epub ahead of print].
"Nociception-induced motor inhibition might prevent effective motor retraining. In addition, the sympathetic nervous system responds to chronic nociception with enhanced sympathetic activation. Not only motor and sympathetic output pathways are affected by nociceptive input, afferent pathways (proprioception, somatosensory processing) are influenced by tonic muscle nociception as well.... The clinical consequence of the shift in thinking is to stop trying to restore normal motor control in case of chronic nociception. Activation of central nociceptive inhibitory mechanisms, by decreasing nociceptive input, might address nociception-motor interactions."
Nijs J, Kosek E, Van Oosterwijck J et al. 2012. Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician. 15(3 Suppl):ES205-213. "Exercise is an effective treatment for various chronic pain disorders, including fibromyalgia, chronic neck pain, osteoarthritis, rheumatoid arthritis, and chronic low back pain. Although the clinical benefits of exercise therapy in these populations are well established (i.e., evidence based), it is currently unclear whether exercise has positive effects on the processes involved in chronic pain (e.g., central pain modulation). A dysfunctional response of patients with chronic pain and aberrations in central pain modulation to exercise has been shown, indicating that exercise therapy should be individually tailored with emphasis on prevention of symptom flares. The paper discusses the translation of these findings to rehabilitation practice together with future research avenues."
Nijs J, Meeus M, Oosterwijck JV et al. 2011. Treatment of central sensitization in patients with 'unexplained' chronic pain: what options do we have? Expert Opin Pharmacother. [Jan 22 Epub ahead of print]. "Acetaminophen, serotonin-reuptake inhibitor drugs, selective and balanced serotonin and norepinephrine-reuptake inhibitor drugs, the serotonin precursor tryptophan, opioids, N-methyl-d-aspartate (NMDA)-receptor antagonists, calcium-channel alpha(2)delta (a2î) ligands, transcranial magnetic stimulation, transcutaneous electric nerve stimulation (TENS), manual therapy and stress management each target central pain processing mechanisms in animals that - theoretically - desensitize the CNS in humans. To provide a comprehensive treatment for 'unexplained' chronic pain disorders characterized by central sensitization, it is advocated to combine the best evidence available with treatment modalities known to target central sensitization." [This is not a sufficient way to treat central pain. One must also identify and bring under maximum control all pain generating factors. For example, if there are morphological pain generators in the spine such as tears in the disc or facet joint inflammation, if there is visceral disease, if there is cancer, if there are myofascial trigger points, one must find the perpetuating factor–and all of its perpetuating factors–and bring them under control. Only then can central pain be successfully treated, and not just masked. DJS]
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use information obtained from the medical diagnosis,
combined with the medical history of the patient, as well as
the clinical examination and the analysis of the treatment
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The clinical examination used to recognize central
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