Oaklander AL, Herzog ZD, Downs H et al. 2013. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain. [Jun 5 Epub ahead of print.] "Fibromyalgia is a common, disabling syndrome that includes chronic widespread pain plus other diverse symptoms….In contrast, small-fiber polyneuropathy (SFPN), despite causing similar symptoms, is definitely a disease caused by dysfunction and degeneration of peripheral small-fiber neurons…..41% of skin biopsies from fibromyalgia subjects vs. 3% of biopsies from control subjects were diagnostic for SFPN, and MNSI (Michigan Neuropathy Screening Instrument) and UENS (Utah Early Neuropathy Scale) scores were higher among fibromyalgia than control subjects…. Abnormal AFT (Autonomic Function Testing) was equally prevalent suggesting that fibromyalgia-associated SFPN is primarily somatic. Blood tests from all 13 fibromyalgia subjects with SFPN-diagnostic skin biopsies provided insights into etiologies. All glucose tolerance tests were normal, but eight subjects had dysimmune markers, 2 had hepatitis C serologies, and one family had apparent genetic causality. These findings suggest that some patients with chronic pain labeled as "fibromyalgia" have unrecognized small-fiber polyneuropathy, a distinct disease that can be objectively tested for an sometimes definitively treated."
Oberklaid F, Amos D,
Liu C et al. 1997. “Growing pains”: clinical and
behavioral correlates in a community sample. J Dev
Behav Pediatr 18(2):102-106. Parents consider children
with growing pains to have different behavioral and
temperamental profiles than healthy children. [There
is no acknowledgement in this study that the presence of
chronic pain could contribute to the behavior problems,
rather than the reverse. DJS]
F., D. Amos, C. Liu, F. Jarman, A. Sanson and M. Prior. 1997.
"Growing pains": clinical and behavioral correaltes
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O'Brien EM, Waxenberg LB,
Atchison JW et al. 2010. Negative mood mediates the effect
of poor sleep on pain among chronic pain patients. Clin J
Pain. 26(4):310-319. “These findings suggest that
addressing negative mood directly, or by addressing sleep
disturbances in chronic pain patients, may have a beneficial
impact on patients' pain. As sleep disturbance may be
causing negative mood, treating the sleep disturbance may
also be beneficial among chronic pain patients. Negative
mood may perpetuate the impact of sleep disturbances on
pain, possibly through increased arousal or disruptions in
O’Brien EM, Staud RM, Hassinger
AD et al. 2009. Patient-centered perspective on treatment
outcomes in chronic pain. Pain Med. [Sep 1 Epub
ahead of print]. “Results highlight the importance of
assessing the patient’s view of successful outcome. Both
fibromyalgia and back pain patients appear to have stringent
criteria for success that existing treatments are often unlikely
to meet. Comparison across groups indicated fibromyalgia
patients have higher than usual levels of pain, fatigue,
distress, and interference. Interestingly, fibromyalgia
patients also require greater changes across domains in order to
consider treatment successful, despite rating higher levels of
pain, fatigue, distress, and interference as successful.
Recognizing patients’ success criteria and treatment
expectations encourages discussion and development of
individualized treatment goals, and wider implementation of
individualized treatment for chronic-pain populations is
O'Brien EM, Waxenberg LB, Atchison JW et al. 2011. Intraindividual Variability in Daily Sleep and Pain Ratings among Chronic Pain Patients: Bidirectional Association and the Role of Negative Mood. Clin J Pain. [Mar 16 Epub ahead of print]. "These findings suggest that addressing sleep is important in the treatment of individuals with chronic pain."
Ocana M, Cendan CM, Cobos EJ et al.
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al. 2005. Hypermobility in women with fibromyalgia
syndrome. Clin Rheumatol. [Oct 16 Epub ahead of
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with FS than in those in the control group. Therefore,
the relationship between hypermobility and FS should be
taken into consideration in the diagnosis and follow-up of
women, especially those with widespread pain.”
Oh S, Kim HK, Kwak J et al. 2013. Causes of hand tingling in visual display terminal workers. Ann Rehabil Med. 37(2):221-228. "To offer the basic data about the causes and distribution of hand tingling, symptoms and physical findings, and pressure pain threshold in desk workers… Five physiatrists participated in the screening test composed of history and physical examination. A total of 876 desk workers were evaluated and of them 37 subjects with hand tingling were selected. For further analyzing, detailed history taking and meticulous physical examination were taken. Pressure pain threshold (PPT) at the infraspinatus, upper trapezius, flexor carpi radialis, rhomboideus, and flexor pollicis longus were examined. PPT measurements were repeated three times with two minute intervals by a pressure algometer. Electrodiagnostic study was done to detect potential neurologic abnormalities….THE CAUSES OF HAND TINGLING IN ORDER OF FREQUENCY WERE: myofascial pain syndrome, 68%; cervical radiculopathy, 27%; rotator cuff syndrome, 11%; tenosynovitis, 8%; and carpal tunnel syndrome, 5%. The location of trigger points in the myofascial pain syndrome, which were proven to evoke a tingling sensation to the hand in order of frequency were: infraspinatus, 65.4%; upper trapezius, 57.7%; flexor carpi radialis, 38.5%; rhomboideus 15.4%; and flexor pollicis longus 11.5%. The PPT of the affected side was significantly lower than that of the unaffected side in myofascial pain syndrome (p<0.05)…The most common cause of hand tingling in desk workers was myofascial pain syndrome rather than carpal tunnel syndrome. Common trigger points to evoke hand tingling were in the infraspinatus and upper trapezius."
Oh TH, Hoskin TL, Luedtke CA et al. 2012. Predictors of clinical outcome in fibromyalgia after a brief interdisciplinary fibromyalgia treatment program: single center experience. PM R. 4(4):257-263. "Patients with younger age, more years of education (with college or graduate degree), higher baseline FIQ depression score, lower tender point count, and absent abuse history experience greater benefit from a brief fibromyalgia treatment program." [The Mayo Clinic has such a program, and generated this research. It is not known if patients are taught about co-existing myofascial trigger points at this clinic. DJS]
Ohayon MM. 2005. Prevalence and
correlates of nonrestorative sleep complaints. Arch
Intern Med. 165(1):35-41. “Nonrestorative sleep is
a frequent symptom in the general population, but its
prevalence largely varies between countries.
Nonrestorative sleep affected more frequently the active
classes of the population and caused greater daytime
impairment than difficulty initiating or maintaining sleep.”
Ohta H, Oka H, Usui C et al. 2012. A randomized, double-blind, multicenter, placebo-controlled phase III trial to evaluate the efficacy and safety of pregabalin in Japanese patients with fibromyalgia. Arthritis Res Ther. 14(5):R217. "This trial demonstrated that pregabalin, at doses of up to 450 mg/day, was effective for the symptomatic relief of pain in Japanese patients with fibromyalgia. Pregabalin also improved measures of sleep and functioning and was well tolerated. These data indicate that pregabalin is an effective treatment option for the relief of pain and sleep problems in Japanese patients with fibromyalgia."
Okifuji A, Donaldson GW, Barck L et al. 2010. Relationship between fibromyalgia and obesity in pain, function, mood, and sleep. J Pain. [Jun 8 Epub ahead of print]. "Fibromyalgia syndrome (FMS) is a prevalent and disabling chronic pain disorder.…
A total of 215 FMS patients completed a set of self-report inventories to assess FMS-related symptoms and underwent the tender point (TP) examination, physical performance testing, and 7-day home sleep assessment. Forty-seven percent of our sample was obese and an additional 30% was overweight. Obesity was related significantly to greater pain sensitivity to TP palpation particularly in the lower body areas, reduced physical strength and lower-body flexibility, shorter sleep duration, and greater restlessness during sleep….The results suggest that obesity may aggregate FMS and weight management may need to be incorporated into treatments."
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Okumus M, Gokoglu F, Kocaoglu S et al. 2006. Muscle performance in patients with fibromyalgia. Singapore Med J. 47(9):752-756. "Our results indicate that osteoporotic patients with FMS have impairment in strength of lumbar and abdominal muscles an in measurement of chest expansion. Further studies are needed to investigate the mechanism of reduced muscle performance and the effects of aerobic exercise in this patient group." [As FM patients have TrPs and TrPs in the indicated muscles and other respiratory muscles can profoundly affect breathing, it perhaps would be wise to discover if the difference in muscle performance was due to co-existing TrPs. DJS]
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Neurosci Lett 342(3):206-210. This article
explains how antidepressants, but not tranquilizers, affect
the glucocorticoid receptors indirectly, affecting the
hyperactivity of the HPA axis (common in FMS).
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Oliveira-Campelo NM, de Melo CA, Alburquerque-Sendín F et al. 2013. Short- and Medium-Term Effects of Manual Therapy on Cervical Active Range of Motion and Pressure Pain Sensitivity in Latent Myofascial Pain of the Upper Trapezius Muscle: A Randomized Controlled Trial. J Manipulative Physiol Ther. [Jun 11 Epub ahead of print]. "Manual techniques on upper trapezius with latent trigger point seemed to improve the cervical range of motion and the pressure pain sensitivity. These effects persist after 1 week in the IC (ischemic compression) group."
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structures in the neck have a dramatic effect on the
magnitude of shortening of the activated GG (genioglossus)
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All reports agree that sexual function seems frequently
impaired in this condition. This dysfunction is
usually severe and may affect all domains of sexuality.
Given the complexity of factors involved in human sexual
function and the intricacy of the physiopathology of FM,
many factors and mechanisms have been implicated. Per
our literature review, depression may be the main
contributing factor to FM-related sexual dysfunction.
However, prospective studies are needed, as reports have
lacked sufficient quality to draw definitive conclusions.
Recognition of sexual dysfunction and its inclusion in
multidisciplinary management are needed to improve quality
of life for patients with FM.” [It is greatly to be hoped
that future research will consider that much of these
symptoms attributed to FM are actually due to co-existing
TrPs, well-documented as causing sexual dysfunction in both
male and female patients. DJS]
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121(2):105-108. Much deep pain in the scapular region may be
helped by “...infiltrating a trigger point in the subscapularis
region of the medical aspect of the scapular spine (root of the
scapular spine) with a mixture of 2cc plain 1% lidocaine
hydrochloride...plus 1 cc beta-methasone sodium phosphate and
acetate suspension...followed by physical therapy exercises.
190 patients (43.19%) received one block, 175 (39.77%) received
two blocks, and 75 (17.04%) received three blocks. Upon
completion of treatment, 97.7% of the patients were relieved of
their discomfort and returned to their original occupation.”
[Since this was published, one must wonder how many patients
with similar symptoms have been subjected to unnecessary
Orr, R. D. and G.
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in the treatment of nighttime gastroesophageal reflux.
Digestion 72(4):229-238. “Approximately three quarters
of individuals who suffer from gastroesophageal reflux disease (GERD)
experience its symptoms at night. Nighttime GERD symptoms
disturb sleep and diminish quality of life more so than daytime
symptoms. Nighttime gastroesophageal reflux is common in
individuals with respiratory disorders such as sleep apnea and
asthma, and may affect the severity and the frequency of these
disorders. The treatments of choice for nighttime GERD
symptoms are proton pump inhibitors (PPIs) due to their efficacy
in relieving daytime and nighttime GERD symptoms and controlling
Orr WC, Heading R, Johnson LF et al.
2004. Review article: sleep and its relationship to
gastro-oesophageal reflux. Aliment Pharmacol Ther
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syndrome and obesity seem to predispose patients to
nocturnal GERD. Recognition and treatment of
night-time GERD are important because it can be associated
with decreased quality of life (including sleep disruption)
and increased risk of serious oesophageal and respiratory
Orstavik K, Norheim I, Jorum E. 2006.
Pain and small-fiber neuropathy in patients with hypothyroidism.
Neurology 67(5):786-791. “Some patients treated for
hypothyroidism have symptoms and findings compatible with
small-fiber neuropathy or ‘hyperphenomena’ indicating central
sensitization.” This is another study showing a link
between FMS and hypothyroid.
Sanli A, Eryuksel R et al. 2010. Association between serum
ferritin level and fibromyalgia syndrome. Eur J Clin Nutr.
[Jan 20 Epub ahead of print] “Iron is essential for a
number of enzymes involved in neurotransmitter synthesis.
Analysis of cerebrospinal fluid in fibromyalgia syndrome
(FMS) has shown a reduction in the concentration of biogenic
amine metabolites, including dopamine, norepinephrine and
serotonin…. A total of 46 patients with primary FMS
participated in this case-control study, and 46 healthy
females who were age matched to the patients were used as
the control group….Our study implicates a possible
association between FM and decreased ferritin level, even
for ferritin in normal ranges. We suggest that iron as a
cofactor in serotonin and dopamine production may have a
role in the etiology of FMS.” [Decreased muscle ferritin
level is also a perpetuating factor for TrPs, and TrPs often
maintain FM central sensitization. One must be careful,
however, as increased iron in post-menopausal women can
increase cholesterol levels. For people with multiple
co-existing interactive conditions it is not easy. DJS]
Ortega-Santiago R, de-la-Llave-Rincon AI, Laguarta-Val S et al. 2012. [Neurophysiological advances in carpal tunnel syndrome: process of central sensitization or local neuropathy]. Rev Neurol. 54(8):490-496. [Spanish] "Several studies…support the presence of a complex process of peripheral and central sensitization in patients with CTS which may constitute a negative prognosis factor for the management of these patients….The advances in neurosciences in the last years support the presence of peripheral and central sensitization mechanisms in CTS. These mechanisms justify the necessity of conceptual changes and in the management, both conservative and surgical, of this syndrome. Additionally, central sensitization can also play a relevant role in the prognosis of CTS since it can constitute a negative prognosis factor for its treatment.
Gatt IT. 2010.
Management of shoulder injuries using dry needling in
elite volleyball players.
Acupunct Med. 28(1):42-45. “These case reports
describe the short-term benefits of dry needling in
shoulder injuries in four international female
volleyball athletes during a month-long intense
competitive phase, using both replicable subjective and
objective measures. Dry needling of scapulohumeral
muscles was carried out. Range of movement, strength and
pain were assessed before and after treatment, with a
functional assessment of pain immediately after playing
and overhead activity, using the short form McGill Pain
Questionnaire. All scores were improved post-treatment
and athletes were able to continue overhead activities.
Previous studies have suggested that myofascial trigger
points may cause significant functional weakness and
reduced range of motion, with referred pain. Trigger
point dry needling has been successful in treating
athletes with myofascial pain and impingement symptoms
but with only subjective improvement and not during a
competitive phase. These cases support the use of dry
needling in elite athletes during a competitive phase
with short-term pain relief and improved function in
shoulder injuries. It may help maintain rotator cuff
balance and strength, reducing further pain and
injury.” [Although this study was done on volleyball
players, it can be extrapolated to professional sports.
Considering the amount of money involved with athletes
and the invasiveness, expense and sometimes
career-limiting effect of surgery, it is certainly in
the interest of the insurance companies to become
proficient in the field of myofascial pain. Right now
the reimbursement system doesn’t cover many myofascial
treatments, but does cover the surgery, and this must be
changed. Many rotator cuff and other soft tissue
injuries could be treated effectively and risk of
further injury minimized if the trigger points were
1994. Craniomandibular/temporomandibular/cervical implications
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Calcium 15(3):437-441. [Japanese] Trigger point
block is one of the common procedures discussed in this
paper on low back pain.
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clinical utility of low-dose fentanyl transdermal system in
patients with chronic nonmalignant pain. Curr Med
Res Opin. 22(8):1493-1501. This lower-dose
fentanyl may be of benefit to opioid-naive patients and the
elderly. It had a beneficial therapeutic effectiveness
with a lessened drop out rate.
Ouyang A, Wrzos HF. 2006.
Contribution of gender to pathophysiology and clinical
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effect on neuromuscular stability, performance,
multi-joint coordination and proprioception of barefoot,
taping or preventative bracing.
Foot (Edinb). 19(4):205-210. “… bracing and
taping may play an important role in preventing injury
or rehabilitation of the injured ankle by improving
concentric and eccentric coordination, proprioception
with the ability of reproducing motion in closed kinetic
chain while decreasing vertical jump performance. No
superiority of brace over tape or vice versa was found
in this study.”
Ozgocmen S, Kaya A, Gulkesen A et al.
2006. Comparison of pain threshold, health and
functional status of females with fibromyalgia and multiple
sclerosis: a pilot study. Int J Psych Clin Pract.
10(3):160-165. FMS and MS share many psychosocial and
clinical features. Controlling chronic pain, fatigue,
social and emotional reactions and disability are important
in both conditions.
Ozgocmen, Salih. 2005. New
strategies in evaluation of therapeutic efficacy in
fibromyalgia syndrome. Current Pharmaceutical
Design [November Epub ahead of print]. “The use of
multiple outcome variables reflecting the complexity of FM
and co-morbid syndromes makes it difficult to evaluate the
efficacy or effectiveness of the treatment in clinical
trials. Additionally, researchers inevitably rely on
patients’ self-reported outcome data, which is prone to
error and bias.” “Clinicians and researchers now have
various highly validated and adequate outcome domains to
assess FM symptoms and new researches continue to add new
valuable domains. Nevertheless the current problem is
to conclude which treatment works best for whom and which
are the outcome domains suitable for FM patients or
patients’ subgroups with different prominent features.
Standardized and appropriate core outcome domains for FM
clinical trails will encourage more complete investigations,
relevant outcome reporting and well-designed multicenter
Ozgocmen S, Ozyurt H, Sogut S et al.
2005. Current concepts in the pathophysiology of
fibromyalgia: the potential role of oxidative stress and
nitric oxide. Rheumatol Int. [Nov 20 Epub ahead
of print] “Researches on genetics, biogenic amines,
neurotransmitters, hypothalamic-pituitary-adrenal axis
hormones, oxidative stress, and mechanisms of pain
modulation, central sensitization, and autonomic functions
in FM revealed various abnormalities indicating that
multiple factors and mechanisms are involved in the
pathogenesis of FM. Oxidative stress and nitric oxide
may play an important role in FM pathophysiology; however,
it is still not clear whether oxidative stress abnormalities
documented in FM are the cause or the effect. This
should encourage further researches evaluating the potential
role of oxidative stress and nitric oxide in the
pathophysiology of FM and the efficacy of antioxidant
treatments (omega-3 and –6 fatty acids, vitamins and others)
in double blind and placebo controlled trials.”
Ozgocmen S, Ozyurt H., Sogut S et al.
2005. Antioxidant status, lipid peroxidation, and
nitric oxide in fibromyalgia: etiologic and therapeutic
concerns. Rheumatol Int. Nov 10:1-10.
[Epub ahead of print] This article offers several possible
therapeutic avenues for fibromyalgia treatment by indicating
possible metabolic subsets.
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event related potentials and serotonin reuptake inhibitor
treatment in patients with fibromyalgia. Ann Rheum
Dis 62(6):551-5. P300 amplitude components of
auditory event potentials, as measured by scalp electrodes, are associated with attention allocation, information
and cognitive processing, and maintenance of working memory.
In fibromyalgia patients, P300 amplitudes are reduced.
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and Myofascial Pain Syndromes, Yonsei Medical Journal
41(5):541-545, 2000. Significant changes to the lipid profile
seems to be part of the myofascial component rather than the
fibromyalgia component when these conditions occur together.
Ozkan F, Cakir Ozkan N, Ekorkmaz U. 2011. Trigger point injection therapy in the management of myofascial temporomandibular pain. Agri 23(3):119-125. "Myofascial pain is the most common temporomandibular disorder.....Our results indicate that trigger point injection therapy combined with splint therapy is effective in the management of myofascial TMD pain. " Further research is needed. [One must be careful with splint use in TrPs, as immobility is a perpetuating factor of TrPs. One needs to treat all the TrPs affecting the TMJ, including the soleus. Unless one knows all TrPs, one may not know to check the calf for TrPs that can affect the jaw. DJS]
Oztürk O, Tek M, Seven H. 2012. Temporomandibular disorders in scuba divers - an increased risk during diving certification training. J Craniofac Surg. 23(6):1825-1829. The design and fit of a mouthpiece on SCUBA can increase the risk of developing TMJD and TrPs as the diver is constantly struggling to attain mouthpiece stability.
JB, Nagle D. 1976. Piriform syndrome. West J Med.
124(6):435-439. Piriformis TrPs are often mistaken as
discogenic pain, causing unnecessary pain, cost and delay of
adequate treatment. Symptoms can include female
dyspareunia, low back pain and hip pain radiating down the
leg, and muscle weakness.
Pachas WN, Bekken KN.
2007. Development of fibromyalgia syndrome following
traumatic brain injury. J Musculoskel Pain 15
(Supp 13):56 item 100. [Myopain 2007 Poster] “In all
patients there was a clear relationship between the time of
their TBI (traumatic brain injury) and subsequent FMS.”
“The factors involved in TBI as the cause or as an
initiating factor of FMS are unknown. Our data suggest
that there might be a connection between these disorders.”
Pachas WN, Bekken KN. 2007. The
role of memantine in the treatment of the memory dysfunction
of patients with fibromyalgia syndrome. J
Musculoskel Pain 15 (Supp 13):42 item 73. [Myopain
2007 Poster] “Memantine improves memory and function in
patients with Alzheimer’s. The possibility that FMS
patients may also benefit was explored in this trial.”
“Sixteen patients were treated with memantine, 3 patients
did not improve. The other patients had moderate to
excellent response, some were able to return to work and
most felt marked improvement in the quality of life.
Neuropsychological testing reflected some of these
changes.” “Memantine is an N-methyl-D-aspartic acid
receptor antagonist.” “Some of the patients on this trial
had a remarkable improvement in their memory and could not
function without it. However, double-blind
placebo-controlled studies should define the value of
memantine in FMS.”
C., Nunn A., Hobbs R. et al. 2002. High density
lipoprotein: guardian of the vascular system?
Int J Clin Pract 56(10):761-71.
“Patients with low HDL-C levels often have central obesity,
insulin resistance and other features of the metabolic
syndrome. This syndrome is both increasingly common and
strongly implicated in the growing worldwide epidemic of type
2 diabetes . . . . Although current guidelines are beginning
to recognize the protective role of HDL-C level in preventing
coronary events, HDL-C should be adopted soon as a target for
intervention in its own right.”
M, Mehta N, White GE. 1987. Trigger point injection: a
neglected modality in the treatment of TMJ dysfunction.
J Pedod. 12(1):72-92.
Pagotto U, Marsicano G, Cota D et al.
2005. The emerging role of the endocannabinoid system in
endocrine regulation and energy balance. Endocr Rev.
[Nov 23 Epub ahead of print] [The role of the endocannabinoid
system includes the modulation of all the endocrine
hypothalamic-peripheral endocrine axes, control of reproduction
and sexual behavior, control of appetite and energy balance and
other metabolic areas that are often imbalanced in FMS. DJS]
Painter JT, Crofford LJ, Talbert J. 2013. Geographic variation of chronic opioid use in fibromyalgia. Clin Ther. 35(3):303-311. "Opioid use for the treatment of chronic nonmalignant pain has increased drastically over the past decade. Although no evidence of efficacy exists supporting the treatment of fibromyalgia (FM) with chronic opioid therapy, a large number of patients are receiving this therapy....Geographic variation in chronic opioid use among patients with FM exists at rates similar to those seen in other studies examining opioid use. This large level of geographic variation suggests that the prescribing decision is not based solely on physician-patient interaction but also on contextual and structural factors at the state level. The level of physician and condition prevalence suggest that information dissemination and peer-to-peer interaction may play a key role in adopting evidence-based medicine for the treatment of patients suffering from FM and related conditions. Level of diagnosis prevalence as a predictor of evidence-based practice has not been reported in the literature and is an important contribution to research on geographic variation."
Paira, S. O. 1994.
Fibromyalgia associated with female and urethral syndrome. Clin
ES, Deodhar A, Jones KD, Bennett R. 2002. Impaired growth
hormone secretion in fibromyalgia patients: Evidence for
augmented hypothalamic somatostatin tone. Arthritis
Rheum 46(5):1344-50. "Because pyridostigmine is known
to reduce somatostatin tone, it is surmised that the defective
GH response to exercise in FM patients probably results from
increased levels of somatostatin, a hypothalamic hormone that
inhibits GH secretion."
Pal JS, Desai J, Bajwa Z. 2007.
Superior oblique muscle deinnervation: implications for
differential innervation of myofascial trigger points.
J Musculoskel Pain 15 (Supp 13):66 item 117.
[Myopain 2007 Poster] “SOM (superior oblique muscle)
TrPs may be a cause, as opposed to a consequence, of
headache.” “Eye movement disorders increase risk for
headache due to awkward head tilts and double vision.”
Palestini P, Calvi C, Conforti E et al.
2003. Compositional changes in lipid microdomains of
air-blood barrier plasma membranes in pulmonary interstitial
edema. J Appl Physiol 95(4):1446-1452.
Laufer C, von Luebken F et al. 2010. [Do meniscus injuries
affect postural stability?] Orthopade. [Jan 20 Epub
ahead of print]. [German] Background: Meniscal lesions are
known to cause a loss of proprioception, which plays an
important role in the regulation of postural stability.
This study showed that in spite of “…the presence of an
arthroscopically confirmed meniscal lesion, none of the
stability indexes that we calculated revealed significant
differences in postural stability between the injured and
uninjured sides…..It was surprising to note that the loss of
proprioception in patients with meniscus injuries did not
influence postural stability. Patients with functional knee
instability must therefore be examined for the presence of
further injuries because a meniscal lesion alone cannot
explain instability symptoms.” [It is suggested the authors
look for myofascial trigger points in the regions of the
meniscal lesions in future research, as TrP are often
associated with proprioceptor dysfunction. DJS]
Palomino RA, Nicassio PM, Greenberg MA
et al. 2007. Helplessness and loss as mediators
between pain and depressive symptoms in fibromyalgia.
Pain. [Feb 28 Epub ahead of print] “The findings
confirm the importance of helplessness and demonstrate that
the cognitive meaning of having FM plays a more central role
in predicting depressive symptomatology than illness-related
stressors, such as pain or disability.”
Palstam A, Gard G, Mannerkorpi K. 2013. Factors promoting sustainable work in women with fibromyalgia. Disabil Rehabil. [Jan 22 Epub ahead of print]. "Promoting factors for work were identified, involving individual and environmental factors. These working women with FM had developed advanced well-functioning strategies to enhance their work ability. The development of such strategies should be supported by health-care professionals as well as employers to promote sustainable work in women with FM… Working women with FM appear to have developed advanced well-functioning individual strategies to enhance their work ability. The development of individual strategies should be supported by health-care professionals as well as employers to promote sustainable work and health in women with FM."
Pang, S. F., L. Li, E.
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Panton L, Simonavice E, Williams K et al. 2012. Effects of Class IV Laser Therapy on Fibromyalgia Impact and Function in Women with Fibromyalgia. J Altern Complement Med. [Nov 23 Epub ahead of print]. "This study provides evidence that LHT (laser heat therapy) may be a beneficial modality for women with FM in order to improve pain and upper body range of motion, ultimately reducing the impact of FM."
Panton LB, Kingsley JD, Toole T et al.
2006. A comparison of physical functional performance and
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and older women who are healthy have similar lower-body strength
and functionality, potentially enhancing the risk for premature
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Aggressive pharmacologic treatment of pain. Rheum Dis Clin
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if accompanied by other somatic symptoms and older age.”
Papageorgiou AC, Silman AJ, Macfarlane
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general population sample changing from CWP to no pain, or
vice versa, over a seven year period was very low. This
suggests that pain, once established, is likely to persist
(or recur) especially if accompanied by other somatic
symptoms and older age.”
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in the treatment of refractory postoperative dyspareunia.
Obstet Gynecol. 114(2 Pt 2):484-487. “Refractory
dyspareunia presents a challenging therapeutic dilemma.
Case: A woman with defecatory dysfunction and dysparenuria
presented with stage 2 prolapse. She underwent
laparoscopic and vaginal pelvic floor reconstruction with
excision of endometriosis. The patient experienced
increased dysparenuria and de novo vaginismus postoperatively
that were refractory to trigger point injections, physical
therapy, and medical and surgical management. She
underwent botulinum toxin type A injections into her levator ani
muscles, which allowed her to have sexual intercourse again
after 2 years of apareunia with no recurrence of pain for 12
months. Conclusion: Injecting botulinum toxin into the
levator ani muscles shows promise for postoperative patients who
develop vaginismus and do not respond to conservative therapy.”
[Men and women with sexual dysfunction must be assessed for
myofascial TrPs in the pelvic floor, including perineum, plus
low abdominal wall and rectal and vaginal TrPs. There is
so much unnecessary misery (and cost) due to lack of training on
the part of practitioners. DJS]
Park AJ, Paraiso MF. 2009.
Successful use of botulinum toxin type a in the treatment of
refractory postoperative dyspareunia. Obstet
Gynecol. 114(2 Pt 2):484-487. [This is one more
indication of pain on intercourse caused by trigger points.
Perhaps much of this could be prevented by TrP injections of
topical anesthetic along the surgical incision sites, as
recommended in the myofascial texts. DJS]
Park CH, Huh BK, Lee SH et al. 2011. Efficacy of oblique fluoroscopic approach for stellate ganglion block. J Musculoskel Pain. 19(2):101-104. "The C7 oblique approach SGB (stellate ganglion block) showed the same SGB effects compared with the C7 anterior approach SGB, and did not cause hoarseness. We concluded that the C7 oblique approach SGB may be a beneficial method for patients." Spinal pathology is a frequent perpetuating factor for TrPs in CMP. It is good to have the safest options for controlling spinal pain. DJS]
Park CH, Lee YW, Kim YC et al. 2012. Treatment experience of pulsed radiofrequency under ultrasound guided to the trapezius muscle at myofascial pain syndrome - a case report. Korean J Pain. 25(1):52-54. "Trigger point injection treatment is an effective and widely applied treatment for myofascial pain syndrome. The trapezius muscle frequently causes myofascial pain in neck area. We herein report a case in which direct pulsed radio frequency (RF) treatment was applied to the trapezius muscle. .... RF treatment produced continuous pain relief when the effective duration of trigger point injection was temporary in myofascial pain."
Park HJ, Moon DE. 2010. Pharmacologic management of chronic pain. Korean J Pain. 23(2):99-108. "This article provides a mechanism- and evidence-based approach to improve the outcome for pharmacologic management of chronic pain. The usual approach to treat mild to moderate pain is to start with a nonopioid analgesic. If this is inadequate, and if there is an element of sleep deprivation, then it is reasonable to add an antidepressant with analgesic qualities. If there is a component of neuropathic pain or fibromyalgia, then a trial with one of the gabapentinoids is appropriate. If these steps are inadequate, then an opioid analgesic may be added. For moderate to severe pain, one would initiate an earlier trial of a long term opioid. Skeletal muscle relaxants and topicals may also be appropriate as single agents or in combination. Meanwhile, the steps of pharmacologic treatments for neuropathic pain include (1) certain antidepressants (tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors), calcium channel alpha(2)-delta ligands (gabapentin and pregabalin) and topical lidocaine, (2) opioid analgesics and tramadol (for first-line use in selected clinical circumstances) and (3) certain other antidepressant and antiepileptic medications (topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists). It is essential to have a thorough understanding about the different pain mechanisms of chronic pain and evidence-based multi-mechanistic treatment. It is also essential to increase the individualization of treatment."
Park, J. H., P.
Phothiamat, C. T. Oates, M. Hernanz-Schulman and N. J. Olsen.
1998. Use of P-31 magnetic resonance spectroscopy to
detect metabolic abnormalities in muscles of patients with
fibromyalgia. Arth Rheum 41(3):406-413.
Park SC, Kim KH. 2012. Effect of adding cervical facet joint injections in a multimodal treatment program for long-standing cervical myofascial pain syndrome with referral pain patterns of cervical facet joint syndrome. J Anesth. [May 31 Epub ahead of print]. Addition of therapeutic CFJ (cervical facet joint) injections to a multimodal treatment program is a useful therapeutic modality for patients, especially young patients, suffering from long-standing MPS with referral pain of CFJ syndrome.
Park TJ, Comer C,
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behavior in naked mole-rats: I - Peripheral structures,
innervation, and selective lack of neuropeptides associated
with thermoregulation and pain. J Comp Neurol
naked mole-rat may be a lab model for fibromyalgia.
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Insulin exposure controls the rate of mammalian aging. Mech
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Parrott, Tom. 1999.
Using opioid analgesics to manage chronic noncancer pain in
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JP. 2009. Myofascial syndrome and pain: a
neurophysiological approach. Pathophysiology. [Jun 3 Epub
ahead of print]. This study indicates that TrPs are related to
muscle spindles in the taut bands.
Partonen, T. 1999.
Melatonin-dependent infertility. Med Hypotheses
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pain in fibromyalgia. Brain. 130(Pt 10):2661-2670.
“…unilateral rTMS of the motor cortex induces a long-lasting
decrease in chronic widespread pain and may therefore constitute
an effective alternative analgesic treatment for fibromyalgia.”
Passik SD, Kirsh KL, Whitcomb L et al.
2004. A new tool to assess and document pain outcomes
in chronic pain patients receiving opioid therapy.
Clin Ther 26(4):552-561. “In this study, the PADT
appeared to be a useful tool for clinicians to guide the
evaluation of several important outcomes during opioid
therapy and provide a simple means of documenting patient
Pastore A, Lanna M, Lombardo N et al. 2013. Intravenous infusion of magnesium sulphate during subarachnoid anesthesia in hip surgery and its effect on postoperative analgesia: our experience. Transl Med UniSa. 5:18-21. "Magnesium sulphate is the drug of choice in case of eclampsia, and pre-eclampsia (for the risk of evolution in eclampsia). According to the most recent findings, this drug has also analgesic properties: its use as an adjunct to analgesia is based on a non-competitive antagonism towards the NMDA receptor and on the blocking of calcium channels: these properties prevent the mechanisms of central sensitization due to nociceptive stimulation of peripheral nerves." [This study suggests that magnesium sulphate might prevent the development of central sensitization.] [Other studies show that once central sensitization has developed, magnesium sulphate will not reverse central sensitization. See: Pain Med. 2013 Jul 25. [Epub ahead of print] Intravenous magnesium for chronic complex regional pain syndrome type 1 (CRPS-1). Fischer SG, Collins S, Boogaard S et al. DJS]
Pastore EA, Katzman WB. 2012. Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. J Obstet Gynecol Neonatal Nurs. 2012 Aug 3. [Epub ahead of print]
"Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and successfully treating MFPP."
Patel SB, Kumar SK. 2012. Myofascial pain secondary to medication-induced bruxism. J Am Dent Assoc. 143(10):e67-69.
Patkar AA, Masand PS,
Krulewicz S et al. 2007. A randomized, controlled
trial of controlled release paroxetine in fibromyalgia. Am
J Med. 120(5):448-454. “Paroxetine controlled
release appears to be well-tolerated and improves the
overall symptomatology in patients with fibromyalgia without
current mood or anxiety disorders. However, its effect
on pain measures seems to be less robust.”
Patucchi, E, Fatati G, Puxeddu A. et al. 2003.
[Prevalence of fibromyalgia in diabetes mellitus and
obesity.] Recenti Prog Med 94(4):163-5.
[Italian] This study
indicates that the association between obesity, diabetes
mellitus and fibromyalgia is a significant one. [Perhaps as
common perpetuating factors for FMS? DJS]
Paul TM , Hoo JS, Chae J et al. 2012. Central Hypersensitivity in Patients with Subacromial Impingement Syndrome. Arch Phys Med Rehabil. [Jul 9 Epub ahead of print]. "This study provides further evidence that SIS (secondary hyperalgesia) patients have significantly lower PPTs (pain-pressure thresholds) than controls in both local and distal areas from their affected arm consistent with primary and secondary hyperalgesia, respectively. Data suggest the presence of central sensitization among subjects with chronic SIS."
Paulson, M., A.
Norberg, E. Danielson. 2002. Men living with fibromyalgia-type
pain: experiences as patients in the Swedish health care
system. J Adv Nurs 40(1):87-95. Men with chronic diffuse pain
waited a long time to be referred to a specialty clinic.
If the staff was interested and well-trained, the men
experienced well-being in spite of the recognition that there
was no cure. Lack of respect from the staff caused the
patients to feel neglected, even if they had otherwise
Pavlou M, Quinn C, Murray K et al. 2010. The effect of repeated visual motion stimuli on visual dependence and postural control in normal subjects. Gait Posture. [Dec 6 Epub ahead of print]. "Patients with vestibular dysfunction, migraine and/or anxiety may experience visual vertigo (VV), whereby symptoms are provoked by disorienting visual environments (e.g., supermarkets). Patients with VV over rely on vision for balance (i.e., visually dependent). Visual vertigo significantly improves when vestibular rehabilitation incorporates exposure to optokinetic stimulation (OKS). However, whether OKS exposure induces a reduction in visual dependency is unknown. This study investigated this issue by measuring visual dependency before and after repeated OKS exposure. Twenty-six healthy subjects (10 males; mean age 29.8 years, range 20-42 years) were randomly allocated into an OKS group who underwent graded OKS exposure for five consecutive days, or a no intervention control group. Assessment included the 'Rod and Frame' and 'Rod and Disc' tests where subjects set the subjective visual vertical in darkness, facing a tilted luminous frame or luminous rotating disc, respectively. Postural sway measures were obtained with eyes open, closed and facing the rotating disc. Results showed significant reductions in subjective vertical tilt with the frame and rotating disc for the OKS group only.... Total sway path and mean deviation induced by the rotating stimulus decreased significantly only for the OKS group (p<0.01), as did the Kinetic Quotient (disc rotation/eyes open sway path ratio; p=0.04). The Romberg Quotient (eyes closed/eyes open ratio) showed no change. Findings suggest visual dependency, both at a perceptual and a postural level, can be reduced with short-term graded OKS exposure in healthy subjects. This has important implications for treatment of patients with VV and balance disorders."
Paxton SE. 2011. Perioperative care of the patient with fibromyalgia. AORN J. 93(3):380-389.
Payne P, Crane-Godreau MA. 2012. Meditative movement for depression and anxiety. Front Psychiatry. 4:71. This review from Dartmouth "…focuses on Meditative Movement (MM) and its effects on anxiety, depression, and other affective states. MM is a term identifying forms of exercise that use movement in conjunction with meditative attention to body sensations, including proprioception, interoception, and kinesthesis. MM includes the traditional Chinese methods of Qigong (Chi Kung) and Taijiquan (Tai Chi), some forms of Yoga, and other Asian practices, as well as Western Somatic practices; however this review focuses primarily on Qigong and Taijiquan…. Results suggest that MM may be at least as effective as conventional exercise or other interventions in ameliorating anxiety and depression; however, study quality is generally poor and there are many confounding factors. This makes it difficult to draw definitive conclusions at this time. We suggest, however, that more research is warranted, and we offer specific suggestions for ensuring high-quality and productive future studies."
RJ, Kost KM, Frenkiel S, et al. 2006. Otolaryngeal
inflammation assessed using the reflux finding score in
obstructive sleep apnea. 134(5):836-842. Laryngeal
inflammation is prevalent among OSA patients and correlates
with laryngeal sensory dysfunction, attenuation of the LAR
(laryngeal adductor reflex), and apnea severity. [GERD
may activate laryngeal TrPs. DJS]
Pedrelli A, Stecco C, Day JA. 2009. treating patellar tendinopathy with fascial manipulation. J Bodyw Mov Ther 13(1):73-80. Trigger points in quadriceps muscles can cause kneecap pain with motor incoordination. Fascial manipulation technique of the quadriceps may relieve kneecap pain and dysfunction, and thus the focus of therapy may need to be the anterior thigh.
Williams, ed. April 1996. Occupational
Therapy: Practice Skills for PhysicalDisfunction. Mosby-Year
Book. Chap. 21. Pope-Davis, S. A.
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2003. The role of mean inspiratory effort on daytime
sleepiness. Eur Respir J 21(4):688-694.
“The data from this study indicate the possible important
role of average inspiratory effort in determining subjective
sleepiness in both obstructive sleep apnoea syndrome and
upper airway resistance syndrome patients.”
Pellegrino, M. J., G.
W. Waylonis and A. Sommer. 1989. Familial occurrence of
primaryfibromyalgia. Arch Phys Med Rehabil 70(1):61-63.
Pellegrino, M. J., D.
Van Fossen, C. Gordon, J. M. Ryan and G.W. Waylonis. 1989.
Peng PW. 2012. Tai Chi and Chronic Pain. Reg Anesth Pain Med. [May 17 Epub ahead of print].
Most tai chi studies were found to be of low quality. "Only 5 pain conditions were reviewed: osteoarthritis, fibromyalgia, rheumatoid arthritis, low back pain, and headache. Of these, Tai Chi seems to be an effective intervention in osteoarthritis, low back pain, and fibromyalgia."
Castano ED. 2005. Survey of chronic pain practice by
anesthesiologists in Canada. Can J Anaesth.
52(4):383-389. “While 38% of responding anesthesiologists
were involved in CPP (chronic pain practice), in the majority of
cases, this accounted for less than 20% of their clinical time.
Thirty percent of those involved in CPP had previous training in
pain management. The types of CPP included nerve blocks
(84%) and pharmacological treatment (60%) in non-cancer pain
(85%) and cancer pain (50%) patients.” “Approximately
one-third of anesthesiologists surveyed incorporate chronic pain
in their practice and their pattern of practice is widely
diversified.” Only 30% of these anesthesiologists had
previous training in chronic pain management. Trigger point
injections were responsible for 70% of this work. [One
must wonder how many of the patients had proper placement and
range of motion stretching for their injections, and how much
was done to identify and control the perpetuating factors–both
minimal and necessary parts of proper treatment of TrPs. DJS]
2008. [Comparison between western trigger point of
acupuncture and traditional acupoints] Zhongguo Zhen
Jiu. 28(5):349-352. “Trigger point theory as the soul
of western acupuncture is very similar to acupoint theory of
traditional acupuncture and moxibustion science. After
comparison, it is found that over 92% of trigger points
(235/255) is corresponding to acupoints in anatomy, and the
local pain treated by 79.5% acupoints are similar to
corresponding myofascial trigger point. Both of them can
induce similar linear propagation of needling response, with
complete uniform or basically complete uniform of 76%, and a
part uniform of 14%; next, both of them can treat symptoms of
internal organs such as diarrhea, constipation, dysmenorrheal,
etc. Therefore, they are very similar in anatomic
location, clinical indications, and the linear propagation of
needling response induced by acupuncture, etc.
Pennacchio, E. A., J.
Borg-Stein and D. A. Keith. 1998. The incidence of pain in the
muscles of mastication in patients with fibromyalgia. J
Mass Dent Soc 47(3):8-12.
Penrod JR, Bernatsky S,
Adam V et al. 2004. Health services costs and their
determinants in women with fibromyalgia. J Rheumatol.
31(7):1391-1398. Women with FMS use a high level of both
conventional and complementary medical services.
Although there are significant direct costs associated with
FMS, 70% of the economic burden on the patient is indirect,
and often unrecognized.
G, Navarrete M, Araque A. 2009. Tripartite
synapses: astrocytes process and control synaptic
information. Trends Neurosci.
32(8):421-431. This explanation of a three part
synaptic system of information flow between pre- and
post-synaptic neurons, astrocytes (glial cells) is
elegant. The astrocytes not only respond to synaptic
transmission but regulate it. [Astrocytes are the
controllers of neural plasticity, including the central
sensitization of FM. DJS] Contrasting to the old
view of neuron dominance of information exchange in the
central nervous system, the emerging view indicates that
the synaptic activity is a coordinated effort by both
the glial and the neurons.
Perea G, Araque A. 2005.
Glial calcium signaling and neuron-glia communication.
Cell Calcium [ Aug 13 Epub ahead of print]
“There is a new concept of the synaptic physiology -
‘the tripartite synapse’, where astrocytes exchange
information with the pre- and post-synaptic elements and
participate as dynamic regulatory elements in
neurotransmission. The control of the Ca(2+)
excitability in astrocytes is a key element in this loop
of information exchange. The ability of astrocytes
to respond to neuronal activity and discriminate between
the activity of different synapses, the modulation of
the astrocytic cellular excitability by the synaptic
activity, and the expression of cellular intrinsic
properties indicate that astrocytes are endowed with
cellular computational characteristics that process
Goncalves AL, Peres MF. 2009. Psychological trauma in
chronic pain: implications of PTSD for fibromyalgia and
headache disorders. Curr Pain Headache Rep.
13(5):350-357. “The association of traumatic exposures
with posttraumatic stress disorder (PTSD) and other mental
health conditions is well known. Patients with chronic
pain, particularly headache disorders and fibromyalgia (FM),
associated with psychological traumas need a special
management strategy. Diagnosis of headache disorders
and FM in traumatized patients and collecting the clinical
history of a traumatic event or diagnosing PTSD in chronic
pain patients is of great importance. Psychotherapy
and pharmacotherapeutic options should be started on
patients with comorbid PTSD and headache disorders and/or
FM.” [This article would have been well-served if the
authors had included myofascial TrPs as part of the picture,
as they so obviously are. Recent research abound in which
headaches are part of myofascial pain rather than FM. DJS]
Peres M, Zukerman E, Senne
Soares et al. 2004. Cerebrospinal fluid glutamate levels in
chronic migraine. Cephalalgia 24(9):735-739.
This study indicates that patients with both FMS and
migraines may have a more severe central sensitization
process than patients with FMS who do not have migraines.
The headache intensity of the chronic migraine patients
correlated with cerebrospinal glutamate levels.
Perez-de-Heredia-Torres M, Martínez-Piedrola RM et al. 2013. Bilateral deficits in fine motor control ability and manual dexterity in women with fibromyalgia syndrome. Exp Brain Res. [Jan 26 Epub ahead of print]. "Our findings revealed bilateral deficits in fine motor control ability and manual dexterity in patients with FMS without symptoms in the upper extremity. These deficits are not related to the clinical features of the symptoms
supporting an underlying central mechanism of altered motor control." [These patients should be assessed for the presence of latent TrPs, as they are known (or should be) to co-exist with FM, and can cause deficits in fine motor control and manual dexterity. DJS]
S, Olivan-Blazquez B, Magallon-Botaya R et al. 2010.
Percutaneous electrical nerve stimulation versus dry
needling: effectiveness in the treatment of chronic low back
pain. J Musculoskel Pain. 18(1). “At least one TrP
was found in all patients, most commonly situated in the
quadratus lumborum muscle [97.6 percent]. The improvement
achieved for both treatment groups was similar in all the
measured variables, although the DN (dry needling) group
carried out fewer sessions than the PENS (percutaneous
electrical nerve stimulation) group.” [The term “chronic
low back pain” is a description, not a diagnosis, and our
reimbursement system must be set up to reflect this.
Quadratus lumborum TrPs are potentially disabling and can
cause tremendous amount of pain and dysfunction, and must be
part of the assessment for causes of chronic low back pain.
Pergolizzi J, Ahlbeck K, Aldington D et al. 2013. The development of chronic pain: physiological CHANGE necessitates a multidisciplinary approach to treatment. Curr Med Res Opin. [Jul 3 Epub ahead of print]. "Chronic pain is currently under-diagnosed and under-treated, partly because doctors' training in pain management is often inadequate. This situation looks certain to become worse with the rapidly increasing elderly population unless there is a wider adoption of best pain management practice. This paper reviews current knowledge of the development of chronic pain and the multidisciplinary team approach to pain therapy. The individual topics covered include nociceptive and neuropathic pain, peripheral sensitization, central sensitization, the definition and diagnosis of chronic pain, the biopsychosocial model of pain and the multidisciplinary approach to pain management. This last section includes an example of the implementation of a multidisciplinary approach in Belgium and describes the various benefits it offers; for example, the early multidimensional diagnosis of chronic pain and rapid initiation of evidence-based therapy based on an individual treatment plan. The patient also receives continuity of care, while pain relief is accompanied by improvements in physical functioning, quality of life and emotional stress. Other benefits include decreases in catastrophizing, self-reported patient disability, and depression. Improved training in pain management is clearly needed, starting with the undergraduate medical curriculum, and this review is intended to encourage further study by those who manage patients with chronic pain."
Perneger, T. V., P. K.
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Perrot S. 2012. If fibromyalgia did not exist, we should have invented it. A short history of a controversial syndrome. Reumatismo. 64(4):186-193. "Fibromyalgia is a recent disease, and some physicians remain doubtful about its reality. The history of fibromyalgia is a story of controversies: the fight between subjectivity and cartesianism, and between old mind and body concepts. Fibromyalgia represents the emblematic condition of unexplained medical symptoms, far from well-defined diseases with objective biomarkers. In this review we will follow the fibromyalgia story along the ages and sciences to better understand this complex pain disorder, between soma and psyche, and between medicine and psycho-sociology and to demonstrate that fibromyalgia exists; we have not invented it."
Perrot S, Choy E, Petersel D et al. 2012. Survey of physician experiences and perceptions about the diagnosis and treatment of fibromyalgia. BMC Health Serv Res. 12(1):356. "Fibromyalgia (FM) is a condition characterized by widespread pain and is estimated to affect 0.5-5% of the general population. Historically, it has been classified as a rheumatologic disorder, but patients consult physicians from a variety of specialties in seeking diagnosis and ultimately treatment. Patients report considerable delay in receiving a diagnosis after initial presentation, suggesting diagnosis and management of FM might be a challenge to physicians....A questionnaire survey of 1622 physicians in six European countries, Mexico and South Korea was conducted. Specialties surveyed included primary care physicians (PCPs; n=809) and equal numbers of rheumatologists, neurologists, psychiatrists and pain specialists. The sample included experienced doctors, with an expected clinical caseload for their specialty. Most (>80%) had seen a patient with FM in the last 2 years. Overall, 53% of physicians reported difficulty with diagnosing FM, 54% reported their training in FM was inadequate, and 32% considered themselves not knowledgeable about FM. Awareness of American College of Rheumatology classification criteria ranged from 32% for psychiatrists to 83% for rheumatologists. Sixty-four percent agreed patients found it difficult to communicate FM symptoms, and 79% said they needed to spend more time to identify FM. Thirty-eight percent were not confident in recognizing the symptoms of FM, and 48% were not confident in differentiating FM from conditions with similar symptoms. Thirty-seven percent were not confident developing an FM treatment plan, and 37% were not confident managing FM patients long-term. In general, rheumatologists reported least difficulties/greatest confidence, and PCPs and psychiatrists reported greatest difficulties/least confidence....Diagnosis and managing FM is challenging for physicians, especially PCPs and psychiatrists, but other specialties, including rheumatologists, also express difficulties. Improved training in FM and initiatives to improve patient-doctor communication are needed and may help the management of this condition. [This free article is available on the Internet, and confirms what many patients know all too well. DJS]
Perrot S, Schaefer C, Knight T et al. 2012. Societal and individual burden of illness among fibromyalgia patients in France: Association between disease severity and OMERACT core domains. BMC Musculoskel Disord. 13(1):22. "In a sample of 88 patients with FM from France, we found that FM poses a substantial economic and human burden on patients and society. FM severity level was significantly associated with patients' health status and core symptom domains."
Perruccio AV, Power JD, Badley EM.
2007. The relative impact of 13 chronic conditions
across three different outcomes. J Epidemiol
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individual level, fibromyalgia/chronic fatigue syndrome and
cancer, and to a lesser extent stroke and heart disease,
were associated with an increased risk of both activity
limitations and a self-rated health status of fair or
poor…” “Differences in the ranking of individual risks and
population attributable fractions for different disease and
outcomes are substantial. This needs to be taken into
account when setting priorities, as interventions may need
to be targeted to different conditions depending on which
aspects of health are being considered, and whether the
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Perry CP. 2001. Current concepts of pelvic congestion
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Pelvic congestion is a common contributor of pelvic pain.
Although recognized in the United Kingdom, it is
controversial in the United States. [This paper refers to it
as a condition, but it is a symptom. The causes of pelvic
congestion include blood and lymph vessel entrapment by
myofascial TrPs, and this cause is treatable. DJS]
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allocation presented here challenges the common opinion of
‘blood glucose’ being the main parameter controlled.
The concept of glucose allocation would predict that weight
gain — with abundance of glucose in muscle and fat —
increases feedback to the brain (via hyperleptinemia) which
in turn results in HPA-axis and SNS overdrive, impaired
insulin secretion, and insulin resistance. HPA-axis
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Harris RE, Williams DA et al. 2005. Differences in
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display less relative unpleasantness than healthy controls in
response to random noxious pressure stimuli. These results
are consistent with the concept that chronic pain may reduce the
relative unpleasantness of evoked pain sensations.” Sensitivity
to pain and pain tolerance are different. Patients may
have hyperalgesia, a heightened sensitivity toward pain, but
still have a greater tolerance to pain. This difference
has not been specified in most previous research.
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Mitochondrial dysfunction and molecular pathways of disease.
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This study proposes that many conditions, including
fibromyalgia, have “...underlying pathophysiological
mechanisms in common, namely reactive oxygen species (ROS)
production, the accumulation of mitochondrial DNA (mt DNA)
damage, resulting in mitochondrial dysfunction.. Antioxidant
therapies hold promise for improving mitochondrial
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Pierrynowski MR, Tiidus PM, Galea
V. 2005. Women with fibromyalgia walk with an
altered muscle synergy. Gait Posture
22(3):210-218. “Results show that FS (fibromyalgia
syndrome) and CV (control volunteers) walk with
externally similar stride lengths, times and velocities,
and joint angles and ground reaction forces but they use
internally different muscle recruitment patterns.
Specifically, FS preferentially power gait using their
hip flexors instead of their ankle plantar flexors.”
[This may cause a tendency to develop myofascial TrPs in
specific muscles, or may enhance certain muscle fatigue.
Pierson MJ. 2011. Changes in temporomandibular joint dysfunction symptoms following massage therapy: a case report. Int J Ther Massage Bodywork. 4(4):37-47. "Ten 45-minute massage therapy treatments were administered over a five-week period. The client's progress was monitored by an initial, midway, and final assessment, using range of motion testing, personal interview, an orthopedic test, and postural analysis.....The client participated in a home care routine consisting of stretches, self-massage, postural training, a proprioception exercise, and hydrotherapy.....Results include an increase in maximal opening from 3.1 cm to 3.8 cm, an overall increase in neck range of motion, a decrease in muscle hypertonicity using the Wendy Nickel's Scale, a decrease in pain from 7/10 to 3/10 on a numerical pain scale, and a decline in stress. [TMJD is often due to TrPs, and this combination of therapies deserves further study. DJS]
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Pinals RS, Hassett AL. 2013. Reconceptualizing John F. Kennedy's Chronic Low Back Pain.
Reg Anesth Pain Med. [Jul 29 Epub ahead of print]. "When the medical records for John Fitzgerald Kennedy were made public, it became clear that the 35th President of the United States suffered greatly from a series of medical illnesses from the time he was a toddler until his assassination in November of 1963. Aside from having Addison disease, no condition seemed to cause him more distress than did his chronic low back pain. A number of surgical procedures to address the presumed structural cause of the pain resulted in little relief and increased disability. Later, a conservative program, including trigger point injections and exercises, provided modest benefit. Herein, the mechanisms underlying his pain are evaluated based on more contemporary pain research. This reconceptualizing of John Fitzgerald Kennedy's pain could serve as a model for other cases where the main cause of the pain is presumed to be located in the periphery."
Pincus T, Castrejón I, Bergman MJ et al. 2012. Treat-to-target: not as simple as it appears. Clin Exp Rheumatol. [Oct 16 Epub ahead of print]. "Treat-to-target as a strategy for rheumatoid arthritis (RA) is now widely advocated based on strong evidence. Nonetheless, implementation of treat-to-target raises caveats, as is the case with all clinical care strategies. The target of remission or even low disease activity does not apply to all individual patients, some of whom are affected by concomitant fibromyalgia, other comorbidities, joint damage, and/or who simply prefer to maintain current status and avoid risks of more aggressive therapies. No single universal 'target' measure or index exists for all individual RA patients. An emphasis in most studies on radiographic progression, rather than physical function or mortality, as the most important outcome to document the value of treat-to-target may be inappropriate. Many reports imply that the only limitation to treating all RA patients with biological agents involves costs, ignoring effective results in most patients with methotrexate and other disease-modifying anti-rheumatic drugs (DMARDs) and adverse events associated with biological agents. Indeed, the best outcomes in reported RA clinical trials result from tight control with DMARDs, rather than from biological agents, as does better overall status of RA patients at this time compared to previous decades. Pharmacoeconomic reports may ignore that RA patients are older, less educated, and have more comorbidities than the general population, as well as critical differences in patient status according to the gross domestic product of different countries. While treating to a target of remission or low disease activity, including with biological agents, is appropriate for many patients, awareness of these concerns could improve implementation of treat-to-target for optimal care of all RA patients." [Many patients have RA, FM and CMP and other conditions as well. Improvement of one condition often improves quality of life, although it may not affect the radiological images. Clinicians must learn to treat the patients and not the diagnostic images. DJS]
Pinquart M, Shen Y. 2010. Depressive Symptoms in Children and Adolescents with Chronic Physical Illness: An Updated Meta-Analysis. J Pediatr Psychol. [Nov 18 Epub ahead of print].
"Pediatricians and others working with children with chronic illnesses should screen children with chronic physical illness for symptoms of psychological distress and make appropriate referrals for mental health services, when needed."[All co-existing conditions should be screened for, and psychologists must be aware that co-existing conditions such as vestibular dysfunction, fibromyalgia and myofascial pain may have some symptoms that may be mistaken for psychological. Lack of support for chronic invisible illnesses can often lead to psychological distress. DJS]
Pinto Fiamengui LM, Freitas de Carvalho JJ, Cunha CO et al. 2013. The influence of myofascial temporomandibular disorder pain on the pressure pain threshold of women during a migraine attack. J Orofac Pain. 27(4):343-349. Thirty-four women between the ages of 18-60 were separated into a group with migraine and one with migraine and myofascial pain, that later category being assumed as the same as temporomandibular pain. The pressure pain threshold (PPT) on the masseter, anterior temporalis, and Achilles tendon were taken by algometer when the patients were pain free, and during a migraine. "Results: Significantly lower PPT values were found during the migraine attack, especially for women with concomitant myofascial pain, regardless of the side of the reported pain. Conclusion: Migraine attack is associated with a significant reduction in PPT values of masticatory muscles, which appears to be influenced by the presence of myofascial TMD pain." [Dentists, and psychologists, must become aware of pain and dysfunction-generating TrPs that can occur over the whole body, so that they cease the confusing use of "myofascial pain" as synonymous with TMJD. DJS]
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Plazier M, Dekelver I, Vanneste S et al. 2013. Occipital nerve stimulation in fibromyalgia: A double-blind placebo-controlled pilot study with a six-month follow-up. Neuromodulation. [Oct 7 Epub ahead of print]. "The goal of this study is to evaluate the effectiveness of occipital nerve stimulation (ONS) as a surgical treatment for fibromyalgia in a placebo-controlled design….Eleven patients were selected based on the American College of Rheumatology-90 criteria and implanted with an occipital nerve trial-lead stimulator. Baseline scores for pain, mood, and fatigue were acquired, and patients were randomized in a ten-week double-blinded crossover design with placebo and effective subsensory threshold stimulation (no paresthesias). After finalizing the trial, nine patients were implanted permanently; evaluation was performed prior to surgery and at six months after surgery for pain, fatigue, and mood of the number of trigger points and overall morbidity. Significant results were found during the trial for a decrease in pain intensity (39.74%) on visual analogue scale …and pain catastrophizing scale (PCS) during effective stimulation. A total of 9/11 patients responded to trial treatment; however, in two patients, this might be a placebo effect, recognizable due to the study design. Six months after permanent implantation, pain intensity remained decreased (44.01%) on VAS…. Besides the VAS, significant changes were noted for PCS, fatigue (modified fatigue impact scale), the number of trigger points, and overall morbidity (fibromyalgia impact questionnaire). There were no serious adverse events. Our data strongly suggest that ONS is beneficial in the treatment of fibromyalgia. The beneficial effects are stable at six months after permanent implantation. Subsensory threshold stimulation is feasible in designing a placebo-controlled trial." [Although the authors recognize the importance of the "trigger point count", they fail to recognize the trigger points as the actual generators of pain and dysfunction. Perhaps if the trigger points had been treated and perpetuating factors identified and controlled, the surgery would not have been necessary. Then again, the surgery might have taken care of some of the perpetuating factors. We will not know, because the authors did not understand the role of the trigger points. DJS]
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This very interesting article notes that the US spends
over half of the amount of money spent on pharmaceuticals in
the world, yet our health care is not the best in many areas.
It proposes that it is in the best interest to look first at
non-pharmaceutical methods to promote health, such as healthy
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deficiency was present in 93% of consecutive patients with
nonspecific muscle pain, no matter the season.
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Adequate pain management of acute pain is of vital necessity for
patients with the central sensitization of FM. [It is also
of vital necessity for others to help prevent FM central
Polat A, Ekinci O, Terzioglu B et al. 2011. Treatment of lateral epicondylitis using betahistine dihydrochloride. J Musculoskel Pain. 19(4):201-206. The description of lateral epicondylitis is often given to pain in the area caused by myofascial TrPs, and TrP twitch causes excess histamine at the motor endplate. Betahistadine is a histamine agonist. Interesting. DJS]
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[German] “Both in acute and chronic, unspecific back pain,
the myofascial pain syndrome resulting in muscular dysbalance is
a major factor. For the differential diagnosis, however,
consideration must always be given to concomitant symptoms
(neurological deficits, general symptoms, signs of osteopathy).
Pathophysiologically, the active trigger point corresponds to a
contraction in the muscle fibers that forms in the region of the
a neuromuscular endplate, and leads, via biochemical processes,
to the stimulation of mesochymal nociceptors. Symptomatic
treatment of acute and chronic back pain may be broken down into
a) physical measures, b) local therapeutic regimens, and c)
systemic pharmacotherapy. As medication, non-steroidal
anti-inflammatory drugs, non-opioid analgesics, opioids
analgesics, muscle relaxants, and antidepressives are available,
and are dose-matched to the severity and stage of the condition.
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– not merely in a linguistic sense. Knowledge of the signs
and symptoms typically associated with a trigger point often
obviates the need for time-consuming and expensive technical
diagnostic measures. The assumption that many cases of
unspecific complaints affecting the musculoskeletal system may
be ascribed to MPS makes clear the scope for the saving of
Pongratz DE, Vorgerd M, Schoser BGH.
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disorders, including the myopathological aspects
of inflammatory and metabolic conditions. Exercise
intolerance is a common symptom of many of them, due to
their impact on muscle energy metabolism. MPS due to
TrPs is a more common cause of muscle pain, with
morphological changes noted as contraction discs often
located in the motor endplate area. [Due to the
localized energy depletion of these states, including TrPs,
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devastating in a patient who had a co-existing condition
that already depleted the energy state, such as the
mitochondrial ATP affect of FMS. DJS]
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[Myofascial pain syndrome – frequent occurrence and often
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Perceived regulatory scrutiny does impact physician
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The majority of respondents felt that their formal
medical training did not prepare them to effectively
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by allowing them to remain in chronic pain?
Conversely, are physicians doing patients harm by supporting
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functions of daily life? There is a delicate balance that
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Portenoy, R. K., V.
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antagonist, may improve the balance between analgesia and
Portenoy RK, Ugarte C, Fuller I et al.
2004. Population-based survey of pain in the United
States: differences among white, African American, and
Hispanic subjects. J Pain 5(6):317-328.
“Neither race nor ethnicity predicted disabling pain, but
the minorities had more characteristics identified as
predictors. The data suggest that race and ethnicity
contribute to clinical diversity, but socioeconomic
disadvantage is the more important predictor of disabling
pain. Race and ethnicity influence the presentation
and treatment of chronic pain. Pain was highly
prevalent across groups, and there were racial and ethnic
differences in pain experience and treatment preferences.”
Porter FL, Grunau RE, Anand KJ. 1999.
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intensity and development. Pediatrics
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increased magnitude physiologic and behavioral responses to
increasingly invasive procedures, demonstrating that even
very prematurely born infants respond to pain and
differentiate stimulus intensity. The best approach
may be one of universal precaution to provide pain
management systematically to reduce the acute and long-term
impact of early procedural pain, development, stimulus
intensity, pain response.”
Porter, F. L., R. E.
Grunau and K. J. Anand. 1999. Long-term effects of pain in infants. J Dev Behav Pediatr 20(4):253-61.
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Attitudes and practices of primary care physicians in the
UCSF/Stanford Collaborative Research Network.
University of California, San Francisco. J Fam
Pract 50(2):145-151. “Primary care physicians are
willing to prescribe schedule III opioids as needed, but
many are unwilling to use schedule II opioids around the
clock for CNMP. Individual prescribing practices vary
widely among primary care physicians. Concerns about
physical dependence, tolerance, and addiction are barriers
to the prescription of opioids by primary care physicians
for patients with CNMP.”
Payne RE. 2007. Prostatitis: infection, neuromuscular
disorder, or pain syndrome? Proper patient
classification is key. Cleve Clin J Med. 74
Suppl 3:S63-71. “Prostatitis is a broad term used to
describe inflammation of the prostate that may be associated
with a myriad of lower urinary tract symptoms of sexual
discomfort and dysfunction.” “Prostatitis is
classified into four categories, including acute and chronic
bacterial forms, a chronic abacterial form, and an
asymptomatic form.” “Chronic abacterial prostatitis
(also known as chronic pelvic pain syndrome) is both the
most prevalent form and also the least understood and the
most challenging to evaluate and treat. This form of
prostatitis may respond to non-prostate-centered treatment
strategies such as physical therapy, myofascial trigger
point release, and relaxation techniques. Because the
various forms of prostatitis call for vastly different
treatment approaches, appropriate evaluation, testing, and
differential diagnosis are crucial to effective management.”
Potts JM. 2009.
Nonpharmacological approaches for the treatment of
urological chronic pelvic pain syndromes in men.
Curr Urol Rep. 10(4):289-294. “Chronic
nonbacterial prostatitis, or urological chronic pelvic pain
syndrome (UCPPS), remains a common and often challenging
disorder to evaluate and treat. Employing a more
holistic approach, including urological therapy, physical
therapy, and psychosocial perspectives, may be more
appropriate for most patients. Growing evidence
supports the use of biofeedback, myofascial trigger point
release, prescribed exercise regimens, relaxation
techniques, and supportive counseling to treat men with
UCPPS.” [What is causing the pain? As the work by Dr. Ragi
Doggweiler-Wiygul explains, “nonbacterial Prostatitis” may
often be a way the non-myofascial trained practitioner
describes pain caused by some myofascial TrPs. DJS]
Potvin S, Larouche A, Normand
E et al. 2009. DRD3 Ser9Gly polymorphism is related to
thermal pain perception and modulation in chronic widespread
pain patients and healthy controls. J Pain.
[May 21 Epub ahead of print]. “This experimental study
is the first to relate DNIC (diffuse noxious inhibitory
controls) and TPTs (thermal pain thresholds) to a functional
polymorphism of limbic dopamine-D3 receptors. As
lowered pain thresholds and deficient pain inhibition are
two core features of fibromyalgia, these preliminary results
may help identify a subgroup of FM patients who require
closer medical attention.”
Gannes F., Lagroye I., Haro E et al. 2002. Effects of radio
frequencies emitted by mobile phone on CNS cell cultures.
Glia (Suppl 1):S51-52 [Abstract]. Mobile phones at 900
MHz could induce CNS response on the cellular level.
Prasanna, A. 1993.
Myofascial pain as postoperative complication. J Pain Sympt
Prateepavanich, P., V.
Kupniratsaikul and T. Charoensak. 1999. The relationship
between myofascial trigger points of gastrocnemius muscle and
nocturnal calf cramps. J Med Assoc Thai82(5):451-9.
Prato, F. S., J. J.
Carson, K. P. Ossenkopp, and M. Kavaliers. 1995. Possible
mechanisms by which extremely low frequency magnetic fields
affect opioid function. FASEB J 9(9):807-14.
Press, J., M. Phillip,
L. Neumann, R. Barak, Y. Segev, M. Abu-Shakra and D. Buskila.
Normal melatonin levels in patients with fibromyalgia
syndrome. J Rheumatol 25(3):551-555.
HG, Bagchi D, Bagchi M. 2002. Protective effects of a
novel niacin-bound chromium complex and a grape seed
proanthocyanidin extract on advancing age and various aspects of
syndrome X. Ann N Y Acad Sci. 957:250-259.
Chronium or grape seed supplementation may be helpful to control
insulin resistance and age-related conditions.
Prevalence of mitral
valve prolapse in primary fibromyalgia: a pilot
Arch Phys Med Rehabil 70(7):541-543.
Zhou Q, Moshiree B et al. 2006. Peripheral and central
contributions to hyperalgesia in irritable bowel syndrome.
J Pain 7(8):529-535. “Pain in irritable bowel
syndrome is likely to be at least partly maintained by
peripheral impulse input from the colon/rectum and central
sensitization.” Central sensitization contributes to IBS
and is at least partly maintained by peripheral pain stimuli and
is in this way similar to FMS.
Price DD, Staud R. 2005.
Neurobiology of fibromyalgia syndrome. J Rheumatol
Suppl. 75:22-28. “Accumulating evidence suggests
that fibromyalgia syndrome (FM) pain is maintained by tonic
impulse input from deep tissues, such as muscle and joints,
in combination with central sensitization mechanisms.
This nociceptive input may originate in peripheral tissues
(trauma and infection) resulting in hyperalgesia/allodynia
and/or central sensitization. Such alterations of
relevant pain mechanisms may lead to long term neuroplastic
changes that exceed the antinociceptive capabilities of
affected individuals, resulting in ever-increasing pain
sensitivity and dysfunction. Future research needs to
address the important role of abnormal nociception and/or
antinociception for chronic pain in FM.”
Price, D. D., G. N.
Verne. 2002. Brain mechanisms of persistent pain states. J
Musculoskel Pain 10(1/2):73-83. Central sensitization involves
increased activity in the same areas and along the same paths
as acute pain, but there are additional areas involved, and
some of these may be part of psychological factors that occur
in chronic pain.
Prince PB, Rapaport AM,
Sheftell FD et al. 2004. The effect of weather on
headache. Headache 44(6):596-602. This
study supports the influence of weather changes on headache.
Prist V, De Wilde VA, Masquelier E. 2012. Ann Phys Rehabil Med 55(3):174-189. This case report presents a 49-year old woman suffering from widespread pain since 2002. Her gait pattern included hip adduction, flexed hips and knees and bilateral equines hip deformity. She was diagnosed by several clinicians, but each had a different idea of what she had: fibromyalgia with dystonia, CNS injury, Little's disease, intramedullary spinal cord tumor, or multiple sclerosis. The authors conclude that the logical diagnosis is fibromyalgia with dystonia; the dystonia being due to generalized analgesic protective attitude. [The patient was not assessed for myofascial trigger points. If she had been, by someone well-trained in myofascial medicine, the diagnosis might have been different. Other diagnoses may be involved, and central sensitization is certainly part of this patient's cause of misery, but as to what the cause behind the descriptions are, the TrP assessment and postural analysis must be done to complete the picture. DJS].
Procacci, P., M.
Maresca and P. Gepetti. 1999. Neurogenic inflammation and
muscle pain. J Musculoskel Pain 7(1-2):5-12.
Proctor SL, Estroff TW, Empting LD et al. 2012. Prevalence of Substance Use and Psychiatric Disorders in a Highly Select Chronic Pain Population. J Addict Med. [Nov 5 Epub ahead of print]. "Certain populations of patients with complex nociceptive, neuropathic, and myofascial pain syndromes may have a lower prevalence of substance use disorders than the general population. They also have concurrent psychiatric disorders, which should be evaluated and treated concomitantly as part of their chronic pain treatment. Despite the low prevalence of substance use disorders, these patients must be continuously monitored for abuse, misuse, and diversion of their medication. The low prevalence may be attributable to the severity of their illness, the patients' inability to achieve pain relief and obtain pain medications easily, and their persistence in pursuing accurate diagnoses and treatment. A major limitation of this study was that it relied on self-report and there were no urine drug screens to report."
Proske U, Gandevia SC. 2012. The proprioceptive senses: their roles in signaling body shape, body position and movement, and muscle force. Physiol Rev. 92(4):1651-1697. Proprioceptive senses "...include the senses of position and movement of our limbs and trunk, the sense of effort, the sense of force, and the sense of heaviness. Receptors involved in proprioception are located in skin, muscles, and joints. Information about limb position and movement is not generated by individual receptors, but by populations of afferents. Afferent signals generated during a movement are processed to code for endpoint position of a limb. The afferent input is referred to a central body map to determine the location of the limbs in space. Experimental phantom limbs, produced by blocking peripheral nerves, have shown that motor areas in the brain are able to generate conscious sensations of limb displacement and movement in the absence of any sensory input. In the normal limb tendon organs and possibly also muscle spindles contribute to the senses of force and heaviness. Exercise can disturb proprioception, and this has implications for musculoskeletal injuries. Proprioceptive senses, particularly of limb position and movement, deteriorate with age and are associated with an increased risk of falls in the elderly. [Trigger points can cause proprioceptive dysfunction, so this information is very important. DJS]
Proudfoot CJ, Garry EM, Cottrell DF et
al. 2006. Analgesia mediated by the TRPM8 cold receptor in
chronic neuropathic pain. Curr Biol.
16(16):1591-1605. A synthetic with the same properties as mint
oil may be an effective analgesic for some chronic pain when
Przeklasa-Muszynska A, Nosek-Kozdra K,
Muszynski T et al. 2006. [Preemptive analgesia in
postoperative pain for children in otolaryngological department]
Przegl Lek. 63(11):1168-1172. [Polish] “Although much
more about the safe and effective management of pain in children
is now known, this knowledge has not been widely or effectively
translated into routine clinical practice.” [This is very
disturbing as inadequate acute pain management can predispose to
chronic pain. DJS]
Pujol J, Lopez-Sola M, Ortiz H
et al. 2009. Mapping brain response to pain in
fibromyalgia patients using temporal analysis of FMRI.
PloS ONE. 4(4):e5224. “The results suggest that
data-driven fMRI assessments may complement conventional
neuroimaging for characterizing pain responses and that
enhancement of brain activation in fibromyalgia patients may
be particularly relevant in emotion-related regions.”
Punjabi NM, Shahar E, Redline S et al.
2004. Sleep-disordered breathing, glucose intolerance,
and insulin resistance: the Sleep Heart Health Study.
Am J Epidemiol. 160(6):521-530. “Sleep-related
hypoxemia was also associated with glucose intolerance
independently of age, gender, body mass and waist
circumference. The results of this study suggest that
SDB is independently associated with glucose intolerance and
insulin resistance and lead to type 2 diabetes mellitus.”
Puretic MB, Demarin V. 2012. Neuroplasticity mechanisms in the pathophysiology of chronic pain. Clin Croat. 51(3):425-429. "Chronic pain is a widespread healthcare problem with great impact on mental health, professional and family life of the patient. It can be a consequence of many disorders; however, its pathogenesis has not yet been fully understood. Neuroplasticity is the ability of the nervous system to adapt to different changes and it is present throughout life, not only in prenatal period, infancy and childhood. However, in the pathophysiology of chronic pain, neuroplasticity shows its 'dark side'. Due to the central sensitization process, noxious stimuli can produce chronic pain or misinterpretation of non-noxious stimuli (secondary hyperalgesia and allodynia). These changes occur at the level of brain cortex as well at peripheral nerves and receptors. This review summarizes a significant portion of literature dealing with neuroplasticity processes in well known chronic pain conditions such as migraine, chronic posttraumatic headache, low back pain, fibromyalgia, and others." [This review from Croatia is well-thought-out and well-done. It is to be hoped that in the future, these researchers will include papers dealing with central sensitization generating TrPs in their research. DJS]
Putignano, P., G. A.
Kaltsas, M. A. Satta and A. B. Grossman. 1998. The effects of
anti-convulsant drugs on adrenal function. Horm Metab Res
Przekop P, Haviland MG, Morton KR et al. 2010. Correlates of Perceived Pain-Related Restrictions among Women with Fibromyalgia. Pain Med. 11(11):1698-1706. "Women with fibromyalgia reporting the more severe pain-related restrictions were those who had experienced trauma accompanied by physical pain, were older, less educated, more depressed, more hostile, had high BMI (body mass index) scores, and had been treated for fibromyalgia in the last 12 months. Predictors in women with osteoarthritis were age, BMI, treatment in the last 12 months, experience of a major life stressor, and greater depression symptom severity. ....In both groups, age, BMI, treatment in the last 12 months, and depression predicted pain-related restrictions. Experience of a traumatic event with physical pain was the strongest predictor in the fibromyalgia group. These findings may be useful in constructing novel treatments and prevention strategies for pain-related morbidity in fibromyalgia patients." [One can always tell when the researchers are psychologist and/or psychiatrists. The BMI is usually an indication of co-existing insulin resistance, and one can only suspect that the hostility and depression have a lot to do with the failure of the doctors to address the myofascial trigger points causing the symptoms and maintaining central sensitization. DJS]
Przekop P, Haviland MG, Zhao Y et al. 2012. Self-reported physical health, mental health, and comorbid diseases among women with irritable bowel syndrome, fibromyalgia, or both compared with healthy control respondents. J Am Osteopath Assoc. 112(11):726-735. "Physicians often encounter patients with functional pain disorders such as irritable bowel syndrome (IBS), fibromyalgia (FM), and their co-occurrence.... Respondents with IBS reported fewer traumatic and major life stressors and better health (ratings and comorbidity data) than respondents with FM or respondents with IBS plus FM. Overall, respondents with both diseases reported the worst stressors and physical-mental health profiles and reported more diagnosed medical, pain, and psychiatric comorbidities....The results revealed statistically significant, relatively large differences in perceptions of quality of life measures and health profiles among the respondents in the control group and the 3 clinical groups."
Queiroz LP. 2013. Worldwide epidemiology of fibromyalgia. Curr Pain Headache Rep. 17(8):356. "This article reviews the prevalence and incidence studies done in the general population, in several countries/continents, the prevalence of FM in special groups/settings, the association of FM with some sociodemographic characteristics of the population, and the comorbidity of FM with others' disorders, especially with headaches."
Queme F, Taguchi T, Mizumura K et al. 2013. Muscular Heat and Mechanical Pain Sensitivity After Lengthening Contractions in Humans and Animals. J Pain. [Sep 21 Epub ahead of print].
"Mechanical sensitivity of muscle nociceptors was previously shown to increase 2 days after lengthening contractions (LC), but heat sensitivity was not different despite nerve growth factor (NGF) being upregulated in the muscle during delayed-onset muscle soreness (DOMS). The discrepancy of these results and lack of other reports drove us to assess the heat sensitivity during DOMS in humans and to evaluate the effect of NGF on the heat response of muscle C-fibers. Pressure pain thresholds and pain intensity scores to intramuscular injection of isotonic saline at 48°C and capsaicin were recorded in humans after inducing DOMS. The response of single unmyelinated afferents to mechanical and heat stimulations applied to their receptive field was recorded from muscle-nerve preparations in vitro. In humans, pressure pain thresholds were reduced but heat and capsaicin pain responses were not increased during DOMS. In rats, the mechanical but not the heat sensitivity of muscle C-fibers was increased in the LC group. NGF applied to the receptive field facilitated the heat sensitivity relative to the control. The absence of facilitated heat sensitivity after LC, despite the NGF sensitization, may be explained if the NGF concentration produced after LC is not sufficient to sensitize nociceptor response to heat….This article presents new findings on the basic mechanisms underlying hyperalgesia during DOMS, which is a useful model to study myofascial pain syndrome, and the role of NGF on muscular nociception. This might be useful in the search for new pharmacologic targets and therapeutic approaches."
J, Buchanan D, Cohen M et al. 2003. Signification and
pain: a semiotic reading of fibromyalgia. Theor Med
These authors contend that fibromyalgia does not exist.
I wonder if they have read any of the articles in this
reference section. While some researchers are zeroing in
on causes and treatments options for patients with
fibromyalgia, there are still a few who spend their time
creating fodder for lawyers bent on denying benefits and care
to patients with this condition. They are part of the
problem instead of part of the solution and seem determined to
ignore the ever-mounting evidence that fibromyalgia is real
and very treatable, and thus deny early interventions that may
in many cases help prevent full-blown fibromyalgia from
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Bicik, J. Dvorak, J Antinnes, G. K. von Schulthess and A.
Buck. 1999.Relation between neuropsychological and
neuroimaging findings in patients with late whiplash syndrome.
J Neurol Neurosurg Psychiatry 66(4):485-9.
Radanov BP, Sturzenegger M, Di Stefano
G. 1995. Long-term outcome after whiplash injury.
A 2-year follow-up considering features of injury mechanism
and somatic, radiologic, and psychosocial findings.
Medicine 74(5):281-297. “Symptomatic patients were
older, had higher incidence of rotated or inclined head
position at the time of impact, had higher prevalence of
pretraumatic headache, showed higher intensity of initial
neck pain and headache, complained of a greater number of
symptoms, had a higher incidence of symptoms of radicular
deficit and higher average scores on a multiple symptom
analysis, and displayed more degenerative signs on X-ray.
Symptomatic patients scored higher with regard to impaired
well-being and performed worse on tasks of attentional
functioning and showed more concern with regard to long-term
suffering and disability.”
Radanov, B. P., S.
Begre, M. Sturzeneggar and K. F. Augustiny. 1996. Course of
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with age, gender and education pair-matched patients. Pain
Radhakrishnan R, Sluka KA.
2009. Increased glutamate and decreased glycine release in
the rostral ventromedial medulla during induction of a
pre-clinical model of chronic widespread muscle pain.
Neurosci Lett. 457(3):141-145. “We hypothesize that
increased release of excitatory neurotransmitters in the RVM (rostroventromedial
medulla) drives the release of excitatory neurotransmitters in
the spinal cord, central sensitization and the consequent
Rafols, A., J. A.
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Ragab A, Clement P, Vincken W. 2004. Objective
assessment of lower airway involvement in chronic
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Sixty percent of chronic rhinosinusitis patients have lower airway involvement, 24 % had asthma and 36% had
small airway disease. These may often be unsuspected.
Raghavendra V, Tanga FY, DeLeo JA. 2004. Complete
Freunds adjuvant-induced peripheral inflammation evokes
glial activation and proinflammatory cytokine expression in
the CNS. Eur J Neurosci 20(2):467-473.
Proinflammatory cytokines can result from hyperactivation of
glial cells, producing central sensitization.
V, Tanga FY, DeLeo JA. 2004. Attenuation of morphine
tolerance, withdrawal-induced hyperalgesia, and associated
spinal inflammatory immune responses by propentofylline in
rats. Neuropsychopharmacology 29(2):327-334.
This study indicates that propentopylline, a glial cell
modulator and anti-inflammatory agent, can restore the
analgesic efficacy of morpihine.
“These results further support the hypothesis that
spinal glia and proinflammatory cytokines contribute to the
mechanisms of morphine tolerance and associated abnormal pain
Rahman W, Dickenson AH. 2013. Voltage gated sodium and calcium channel blockers for the treatment of chronic inflammatory pain. Neurosci Lett. [Aug 11 Epub ahead of print]. "The inflammatory response is a natural response of the body that occurs immediately following tissue damage, which may be due to injury, infection or disease. The acute inflammatory response is an essential mechanism that promotes healing and a key aspect is the ensuing pain, which warns the subject to protect the site of injury. Thus, it is common to see a zone of primary sensitization as well as consequential central sensitization that generally, is maintained by a peripheral drive from the zone of tissue injury. Inflammation associated with chronic pain states, such as rheumatoid and osteoarthritis, cancer and migraine etc. is deleterious to health and often debilitating for the patient. Thus there is a large unmet clinical need. The mechanisms underlying both acute and chronic inflammatory pain are extensive and complex, involving a diversity of cell types, receptors and proteins. Among these the contribution of voltage gated sodium and calcium channels on peripheral nociceptors is critical for nociceptive transmission beyond the peripheral transducers and changes in their distribution, accumulation, clustering and functional activities have been linked to both inflammatory and neuropathic pain. The latter has been the main area for trials and use of drugs that modulate ion channels such as carbamazepine and gabapentin, but given the large peripheral drive that follows tissue damage, there is a clear rationale for blocking voltage gated sodium and calcium channels in these pain states. It has been hypothesized that pain of inflammatory origin may evolve into a condition that resembles neuropathic pain, but mixed pains such as low back pain and cancer pain often include elements of both pain states. This review considers the therapeutic potential for sodium and calcium channel blockers for the treatment of chronic inflammatory pain states." [This paper confirms the role of peripheral pain generation in initiating the central sensitization state. It is very interesting, considering the idea that trigger points may be associated with a calcium channelopathy. DJS]
Rahn EJ, Guzman-Karlsson MC, David Sweatt J. 2013. Cellular, molecular, and epigenetic mechanisms in non-associative conditioning: Implications for pain and memory. Neurobiol Learn Mem. [Jun 22 Epub ahead of print]. "Sensitization is a form of non-associative conditioning in which amplification of behavioral responses can occur following presentation of an aversive or noxious stimulus. Understanding the cellular and molecular underpinnings of sensitization has been an overarching theme spanning the field of learning and memory as well as that of pain research. In this review we examine how sensitization, both in the context of learning as well as pain processing, shares evolutionarily conserved behavioral, cellular/synaptic, and epigenetic mechanisms across phyla. First, we characterize the behavioral phenomenon of sensitization both in invertebrates and vertebrates. Particular emphasis is placed on long-term sensitization (LTS) of withdrawal reflexes in Aplysia following aversive stimulation or injury, although additional invertebrate models are also covered. In the context of vertebrates, sensitization of mammalian hyperarousal in a model of post-traumatic stress disorder (PTSD), as well as mammalian models of inflammatory and neuropathic pain is characterized. Second, we investigate the cellular and synaptic mechanisms underlying these behaviors. We focus our discussion on serotonin-mediated long-term facilitation (LTF) and axotomy-mediated long-term hyperexcitability (LTH) in reduced Aplysia systems, as well as mammalian spinal plasticity mechanisms of central sensitization. Third, we explore recent evidence implicating epigenetic mechanisms in learning- and pain-related sensitization. This review illustrates the fundamental and functional overlay of the learning and memory field with the pain field which argues for homologous persistent plasticity mechanisms in response to sensitizing stimuli or injury across phyla."
Raikkonen K., Matthews
K.A., Kuller L.H. 2002. The relationship between
psychological risk attributes and the metabolic syndrome in
healthy women: Antecedent or consequence?
Metabolism 51(12):1573-1577. “The
metabolic syndrome is an important risk factor for major
chronic diseases in women....Psychological risk factors affect
the development of the metabolic syndrome. The
association between anger and the metabolic syndrome is
reciprocal. Reduction in the level of psychological
distress may prevent the development of the metabolic syndrome
Rainey CE. 2013. The use of trigger point dry needling and intramuscular electrical stimulation for a subject with chronic low back pain: a case report. Int J Sports Phys Ther 8(2):145-161. The subject of this case report is a 30 year old female on active military duty, who developed low back and right posteriolateral hip pain after a lumbar flexion injury from picking up a barbell. Exam revealed a multi-segmental flexion movement pattern dysfunction, with TrPs in the right gluteus maximus and medius. Dry needling of the trigger points and intramuscular stimulation coupled with a home program of core stability exercises helped the patient return to full military duty without pain.
Rainsford KD. 2006. Influenza
(“Bird Flu”), inflammation and anti-inflammatory/analgesic
drugs. Inflammopharmacology 14(1-2):2-9. This
study is related to fibromyalgia in that avian flu may cause
a pro-inflammatory cytokine storm to kill its victims, and
FMS patients may already be in a cytokine storm, or at least
at a high level of pro-inflammatory cytokine activity.
A number of potential medications are listed, among which
are pentoxifylline, macrolide antibiotics, reservatrol,
flavenoids and EPA. [Reduced anti-inflammatory
cytokines may also be part of the problem. (See
Uceyler N et al 2006 et al.) Statins are also
mentioned, but there is concern due to their potential
adverse affects on co-existing myofascial TrPs.]
Rainville P, Bushnell MC,
2001. Representation of acute and persistent pain in
the human CNS: potential implications for chemical
intolerance. Ann N Y Acad Sci. 933:130-141.
CNS neuroplasticity involved in chronic pain may share
similarities with environmental chemical sensitivity.
Raison CL, Capuron L, Miller AH. 2005.
Cytokines sing the blues: inflammation and the pathogenesis of
depression. Trends Immunol. [Nov 26 Epub ahead of
print] “Depression might be a behavioral byproduct of
early adaptive advantages conferred by genes that promote
inflammation. These findings suggest that targeting
proinflammatory cytokines and their signaling pathways might
represent a novel strategy to treat depression.” [This may
be a helpful treatment strategy for patients with both
depression and FMS. DJS]
Rakovski C, Zettel-Watson L, Rutledge D. 2012. Association of employment and working conditions with physical and mental health symptoms for people with fibromyalgia. Disabil Rehabil. [Feb 12 Epub ahead of print]. "Work modifications could allow more people with FM to remain employed and alleviate symptoms. Persons with FM should be counseled to consider what elements of their work may lead to symptom exacerbation." [To do these modifications adequately, one must take into consideration the peripheral pain generators that are causing and/or maintaining the central sensitization of FM. Controlling the perpetuating factors of the peripheral pain generators can substantially help in the management of FM. DJS]
Raloff, J. 2000. More
Waters Test Positive for Drugs. Sci News157(14):212.
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Ramirez BG, Blazquez C, Gomez del
Pulgar T et al. 2005. Prevention of Alzheimer’s
disease pathology by cannabinoids: neuroprotection mediated
by blockade of microglial activation. J Neurosci.
25(8):1904-1913. “Cannabinoids are neuroprotective
agents against excitotoxicity in vitro and acute brain
damage in vivo. Intracerebroventricular administration
of the synthetic cannabinoid WIN55,212-2 to rats prevent
betaA-induced microglial activation, cognitive impairment,
and loss of neuronal markers. Our results indicate
that cannabinoid receptors are important in the pathology of
AD and that cannabinoids succeed in preventing the
neurodegenerative process occurring in the disease.
[This may have relevance in the treatment of cognitive
deficits in fibromyalgia. DJS]
Rao SG. 2002. The
neuropharmacology of centrally-acting analgesic medications
in fibromyalgia. Rheum Dis Clin North Am
28(2):235-259. “FMS consists of more than just chronic
pain, and the question of how sleep abnormalities,
depression, fatigues, and so forth tie into disordered pain
processing is being researched actively. Future
research focusing on how the various manifestations of FMS
related to one another undoubtedly will lead to a more
rational targeting of drugs in this complex disorder.”
Raouf R, Quick K, Wood JN. 2010. Pain as a channelopathy. J Clin Invest. 120(11):3745-3752. "Mendelian heritable pain disorders have provided insights into human pain mechanisms and suggested new analgesic drug targets. Interestingly, many of the heritable monogenic pain disorders have been mapped to mutations in genes encoding ion channels. Studies in transgenic mice have also implicated many ion channels in damage sensing and pain modulation. It seems likely that aberrant peripheral or central ion channel activity underlies or initiates many pathological pain conditions. Understanding the mechanistic basis of ion channel malfunction in terms of trafficking, localization, biophysics, and consequences for neurotransmission is a potential route to new pain therapies." [This is interesting in that the most likely current hypothesis for the cause of myofascial TrPs is a calcium channelopathy. DJS]
Raphael, J., J.
Southall, G. Treharne et al. 2002. Efficacy and adverse
effects of intravenous lignocaine therapy in fibromyalgia
syndrome. BMC Musculoskel Disord 3(1):21. IV lidocaine may be
a safe and beneficial therapy for fibromyalgia.
Raphael KG, Janal MN, Nayak S et
al. 2006. Psychiatric comorbidities in a community
sample of women with fibromyalgia. Pain
[May 12 Epub ahead of print] “Prior studies of
care-seeking fibromyalgia (FM) patients often report
that they have an elevated risk of psychiatric
disorders, but biased sampling may distort true risk.”
“Although risk of current MDD was nearly 3-fold higher
in community women with than without FM, the groups had
similar risk of lifetime MDD. Risk of lifetime
anxiety disorders, particularly obsessive compulsive
disorder and post-traumatic stress disorder, was
approximately 5-fold higher among women with FM.
Overall, this study found a community prevalence for FM
among women that replicates prior North American studies
and revealed that FM may be even more prevalent among
racial minority women. These community-based data
also indicate that the relationship between MDD and FM
may be more complicated than previously thought, and
call for an increased focus on anxiety disorders in FM.”
Natelson B.H., Janal M.N. et al. 2002. A community-based
survey of fibromyalgia-like pain complaints following the
World Trade Center terrorist attacks. Pain
100(1-2):131-9. “The failure to detect a significant
increase in symptoms consistent with a diagnosis of
fibromyalgia and the failure of new onsets of such symptoms to
be accounted for by exposure to major stressors or prior
depressive symptoms suggests that these hypothesized risk
factors are unlikely to be of major importance in the
pathogenesis of fibromyalgia.”
Rashiq, S. and B. S.
Galer. 1999. Proximal myofascial dysfunction in complex
regional pain syndrome: a retrospective prevalence study. Clin
J Pain 15(2):151-3.
Rask-Anderson, H., A.
Kinnefors and R. B. Illing. 1999. On a novel type of neuron
with proposed mechanoreceptor function in the human round
window membrane–animmunohistochemical study. Rev Laryngol
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M. Boldt, C. W. Wilkinson, S. M. Yellon and A. M. Matsumoto.
1999.Daily melatonin administration at middle age suppresses
male rat visceral fat, plasma leptin, and plasma insulin to
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Rauck R, Busch M, Marriot T. 2012. Effectiveness of a heated lidocaine/tetracaine topcial patch for pain associated with myofascial trigger points: results of an open-label pilot study. Pain Pract. [Dec 10 Epub ahead of print]. "The heated lidocaine/tetracaine patch has potential utility as a noninvasive pharmacological approach for managing MTP pain. Further studies are warranted." [This may be a helpful treatment for one or two trigger points, although perpetuating factors must still be brought under control. DJS]
Ravera S, Bianco B, Cugnoli C
et al. 2009. Sinusoidal ELF magnetic fields affect
acetyl cholinesterase activity in cerebellum synaptosomal
membranes. Bioelectromagnetics. [Dec 29 Epub
ahead of print]. [This article is of interest in that
Simons’ Integrated Hypothesis of myofascial TrP formation
includes the excess amount of acetylcholine produced at the
motor endplate. Anything, even these magnetic fields that
affect the metabolism of acetylcholine, might then impact
TrPs and their ability to heal. DJS]
Rayegani S, Bahrami M, Samadi B et al. 2011. Comparison of the effects of low energy laser and ultrasound in treatment of shoulder myofascial pain syndrome: a randomized single-blinded clinical trial. Eur J Phys Rehabil Med. 47(3):381-389. "Myofascial pain syndrome (MPS) is one of the most prevalent musculoskeletal diseases. MPS impaired quality of life in the patients. There is a lot of controversy about different treatment options which include medical treatments, physical therapy, injections, ultrasound and laser.... This study introduces laser as one of the preferred treatments of myofascial pain syndrome in shoulder." [It is a sad commentary on the state of medical care that most care providers are unaware that this common cause of musculoskeletal pain even exists. DJS]
Rayhan RU, Ravindran MK, Baraniuk JN. 2013. Migraine in gulf war illness and chronic fatigue syndrome: prevalence, potential mechanisms, and evaluation. Front Physiol. 4:181. "The high prevalence of migraine in CFS (chronic fatigue syndrome) was confirmed and extended to GWI (gulf war illness) subjects. GWI and CFS may share dysfunctional central pathophysiological pathways that contribute to migraine and subjective symptoms. The high migraine prevalence warrants the inclusion of a structured headache evaluation in GWI and CFS subjects, and treatment when present."
Rea, T., J. Russo, W.
Katon, R. L. Ashley and D. Buchwald. 1999. A prospective study
of tender points and fibromyalgia during and after an acute
viral infection. Arch Intern Med159(8):865-707.
Kozody R, Barsa JE et al. 1983. Trigger point injections
vs. jet injection in the treatment of myofascial pain.
Pain. 15(2):201-206. “Trigger point injections using
dilute solutions of local anesthetic agents have proved
effective for many patients with myofascial pain. The
treatment itself, however, can produce severe pain and may
occasionally be associated with complications. It was
determined in this study that a local anesthetic solution
administered by jet injection in the area of myofascial trigger
points was capable of providing short-term pain relief equal to
conventional trigger point injections using a hypodermic needle
and syringe. The jet injector system produced
significantly less pain during treatment than conventional
trigger point injections and therefore was preferred by most
subjects having the opportunity to compare both forms of
Joyce C., Zaneveld L.J. 1980. Role of hyaluronidase in
fertilization: The antifertility activity of Myocristin, a
nontoxic hyaluronidase inhibitor. J Androl 1(1):28-32.
Excess hyaluronic acid may be a factor in infertility.
JR, Justo CM, Moraleda FV et al. 2004. Long-term
efficacy of therapy in patients with fibromyalgia: A physical
exercise-based program and a cognitive-behavioral approach. Arthritis
This study showed that “improvement in self-efficacy
and physical fitness are not associated with improvement in
Hauger RL, Gilin JC et al. 2000. Effects of sleep and
sleep deprivation on interleukin-6, growth hormone, cortisol,
and melatonin levels in humans. J Clin Endocrinol
Metab 85(10:3597-3603. There is an association
between sleep stages and IL-6 levels. Populations with
increased REM and relative loss of deep sleep [some FMS
patients may fall in this category. DJS] have elevated
nighttime concentrations of IL-6. This may signify
increased inflammatory disease risk. [It also may be a
cause for chronic pain – see Focus on Pain 2003. DJS]
PH, Wyatt M, O’Flynn P. 1999. Dercum’s disease (adiposis
dolorosa). J Laryngol Otol. 113(2):174-176.
Dercum’s disease, also called lipomtosis dolorosa and a variety
of other names, is characterized by progressively painful fatty
deposits. There is at least 3 months pain in fatty deposits,
and may be excessive fatigue, obesity, and mental disturbances
including confusional states. It is rare, but may be
misdiagnosed as FM, or it may co-exist with FM and some of the
confusional states and other symptoms may be due to co-existing
Reed BD, Harlow SD, Sen A et al. 2012. Relationship between vulvodynia and chronic comorbid pain conditions. Obstet Gynecol. 120(1):145-151. "To estimate the relationship among the presence of vulvodynia, fibromyalgia, interstitial cystitis, and irritable bowel syndrome. Validated questionnaire-based screening tests for the four pain conditions were completed by women with and without vulvodynia who were participating in the Michigan Woman to Woman Health Study, a longitudinal population-based survey in southeastern Michigan. Weighted population-based estimates of the prevalence and characteristics of participants with these chronic comorbid pain conditions were calculated using regression analyses....Chronic pain conditions are common, and a subgroup of women with vulvodynia is more likely than those without vulvodynia to have one or more of the three other chronic pain conditions evaluated. [It is most unfortunate that myofascial trigger points, one of the main co-existing conditions of vulvodynia as well as one of the main causes, was not included in this study. DJS]
elDeeb ME. 1991. Referred pain of muscular origin
resembling endodontic involvement. Case report. Oral
Surg Oral Med Oral Pathol. 71(2):223-227. “Referred
pain is common in the orofacial region and can cause
considerable difficulties in diagnosis. Referred pain is
defined as pain that is referred to a part of the body other
than the site of origin, and as a result, severe pain may arise
without an associated causative lesion. A muscular trigger
point that resembled a tooth with endodontic involvement is
Kilbreath, S.L., Raymond, J. 2003. Deficits in detection
of inversion and eversion movements among subjects with
recurrent ankle sprains. J Orthop Sports Phys Ther
33(4):166-173; discussion 173-6.
“Perception of passive inversion and eversion
movements imposed at the ankle was impaired in subjects with
recurrent ankle sprains.” [This may have implications
for spread of TrPs, involving, among other things,
TrP proprioception dysfunction. DJS]
Regland, B., M.
Andersson, L. Abrahamsson, J. Bagby, L. E. Dyrehag and C. G.
Gottfries. 1997.Increased concentrations of homocysteine in
the cerebrospinal fluid in patients with fibromyalgia and
chronic fatigue syndrome. Scand J Rheumatol
Koroschetz J, Gockel U
et al. 2010.
cross-sectional survey of 3035 patients with fibromyalgia:
subgroups of patients with typical comorbidities and sensory
Rheumatology (Oxford). [Mar 17 Epub ahead of print].
“Patients with FM…present with a variety of pain qualities,
sensory abnormalities and additional comorbidities. The aim
was to identify clinically distinguishable subgroups of
patients….Clinically relevant sensory abnormalities
(strongly, very strongly present) included pressure pain
(58%), prickling (33%), burning (30%) and thermal
hypersensitivity (24%). Pain attacks were complained by 40%
of patients. Moderate to severe comorbid depression occurred
in 66% of patients. Only approximately 30% of the patients
had optimal sleep. A hierarchical cluster analysis using
descriptors of sensory abnormalities as well as the extent
of comorbidities revealed five distinct subgroups of
patients showing a characteristic clinical profile. Four
subgroups of patients suffer from severe sensory
disturbances in various combinations but lack pronounced
comorbidities. In one subgroup, however, severe
comorbidities dominate the clinical picture. ….The results
of this study indicate that FM patients can be classified on
the basis of their sensory symptoms and comorbidities by the
use of a patient-reported questionnaire. Subgrouping of
patients with FM may be used for future research and to
tailor optimal treatment strategies for the appropriate
Reich JW, Johnson LM, Zautra AJ et
al. 2006. Uncertainty of illness relationships
with mental health and coping processes in fibromyalgia
patients. J Behav Med. [May 6 Epub ahead of
print] “Fibromyalgia syndrome (FMS) is a chronic
musculoskeletal pain condition poorly understood in
terms of etiology and treatment by both physicians and
patients. This condition of ‘uncertainty of illness’ was
examined as a variable involved in the adjustment of FMS
patients, relating it to their depression, anxiety,
affect and coping styles.” “Both cross-sectional and
more dynamic longitudinal analyses showed that illness
uncertainty was significantly associated with anxiety,
negative affect, and avoidant and passive coping. Its
positive relationship with depression was eliminated
when a control variable, pain helplessness, was included
as a covariate. Longitudinally, illness uncertainty
interacted with interpersonally stressful daily events
in predicting reports of reduced positive affect,
suggesting that illness uncertainty acts as a risk
factor for affective disturbances during stressful
Reich JW, Olmsted ME, van Puymbroeck CM.
2006. Illness uncertainty, partner caregiver burden and
support, and relationship satisfaction in fibromyalgia and
osteoarthritis patients. Arthritis Rheum.
55(1):86-93. “Partner caregiver burden was related to lower
levels of partner supportiveness for the FMS dyads, but not for
the OA dyads.” “The results suggest that uncertainty of illness
is a prominent feature affecting patients with FMS in their
relationships with their partners.”
Levine JD. 2009. Critical role of nociceptors plasticity
in chronic pain. Trends Neurosci. [Sep 23 Epub
ahead of print] “The transition from acute to chronic pain
states might be the most important challenge in research to
improve clinical treatment of debilitating pain. We
describe a recently identified mechanism of neuronal plasticity
in primary afferent nociceptive nerve fibers (nociceptors) by
which an acute inflammatory insult or environmental stressor can
trigger long-lasting hypersensitivity of nociceptors to
inflammatory cytokines. This phenomenon, ‘hyperalgesic
priming’, depends on the epsilon isoform of protein kinase C (PKCvarepsilon)
and a switch in intracellular signaling pathways that mediate
cytokine-induced nociceptor hyperexcitability. We discuss
the impact of this discovery on our understanding of, and
ultimately our ability to treat, a variety of enigmatic and
debilitating pain conditions, including those associated with
repetitive injury and generalized pain conditions, such as
Reichmann H, Schaefer J. 2004.
Painful myopathies – metabolism of muscle cells and
metabolic myopathies. J Musculoskeletal Pain
12(3/4):75-83. Types of myalgia considered in this article
include causes of focal muscle pain such as restless leg
syndrome and neurogenic pain, causes of diffuse muscle pain
such as FMS, paroxysmal muscle pain such as contractures
(which may be caused by TrPs) and exercise-induced muscle
pain. This excellent article on myopathies makes
several points which are relevant to FMS or TrPs.
There is a clear and detailed explanation of energy
metabolism in muscle mitochondria. There is a clear
explanation of muscle pain pathogenesis in myopathies.
Tissue pH importance, now found to be lowered at the TrP
local twitch response (Shah et al 2005) is highlighted.
Muscle soreness caused by mechanical microrupture of the
sarcomeric structures described in the article may happen in
over-vigorous physical therapy, especially in patients with
the combination of FMS and TrPs. The article describes
the hypersensitivity of FMS patients to normal mechanical
stimuli. A central nervous system disease may cause
secondary myalgia due to spasticity or rigidity.
[Patients with chronic myofascial pain complex may have
muscle tightness to the point of pain.] Contractures
are described briefly as never occurring at rest, but only
after repetitive muscle contractions. [Patients with
chronic myofascial pain complex can have muscles in
permanent contracture. The muscles do not seem to be
able to relax. DJS] Disturbances in muscle metabolism
can cause contractures, and among these are channelopathies.
[It has been proposed that myofascial TrPs are a type of
channelopathy. DJS] “All patients with a defect in
glucose metabolism should have a protein-rich diet.”
Patients must learn to avoid overuse of their muscles, and
“avoid endurance exercise with abnormalities of aerobic
metabolism and to avoid brief intensive exercise with
disturbances of anaerobic metabolism.”
Reid, G. J., B. A.
Lang and P. J. McGrath. 1997. Primary juvenile fibromyalgia:
psychological adjustment, family functioning, coping and
functional disability. Arth Rheum 40(4):752-760.
Reid, W. D. and G.
Dechman. 1995. Considerations when testing and training the
respiratory muscles. Phys Ther 75(11):971-82.
Reidenberg, M. M. and
R. K. Portenoy. 1994. The need for an open mind about the
treatment of nonmalignant pain. Clin Pharmacol Ther
Reiestad F, Kulkarni J. 2013. Role of myofascial trigger points in post-amputation pain: causation and management. Prosthet Orthot Int. 37(2):120-123. "Identification of myofascial trigger points in amputation stumps and their role in post-amputation pain, followed by appropriate intervention is an important facet of management of this complex chronic pain. Clinical relevance Myofascial trigger points in amputation stumps can lead to ongoing chronic post-amputation pain and our results indicate that identification and intervention of these trigger points does lead to notable resolution of this pain."
Reiffenberger, D. H.
and L. H. Amundson. 1996. Fibromyalgia syndrome: a review. Am
Fam Physician 53(5):1698-712.
Reilich P, Fheodoroff K, Kern U et al.
2004. Consensus statement: botulinum toxin in myofascial
pain. J Neurol 251(Suppl 1):1/36-1/38.
Botulinum toxin is suitable for patients with myofascial TrPs
who have poor clinical outcomes after at least a month of
physical therapy, including dry needling and medications.
Two techniques are explained. It must be used with
caution, and only as part of multimodal therapy.
Reilly, P. A. 1999.
The differential diagnosis of generalized pain. Baillieres
Best Pract ResClin Rheumatol 13(3):391-401.
Reimann F, Cox JJ, Belfer I et al. 2010
March 8 Proc Natl Acad Sci USA [Epub ahead of print.]
The gene SCN9A has been shown to be responsible for several pain
disorders in human beings. This study shows that a
nucleotide polymorphism in this gene is also part of central
sensitization through C-fiber activation.
Reisenauer SJ. 2012. A needle in the neck: trigger point injections as headache management in the emergency department. Adv Emerg Nurs J. 34(4):350-356. "A review of recent research suggests that the use of trigger point injections is successful in relieving the acute pain of musculoskeletal headaches. Patients with the chief complaint of headache commonly present to the emergency department (ED) and are often treated with multiple intravenous medications including narcotics....This article will address the problems of intravenous medication therapy and discuss the benefits of trigger point therapy as management for musculoskeletal headaches specifically in the ED. In addition, discussion aims to provide tools for the nurse practitioner to integrate this skill into clinical practice."
Reisine S, Fifield J, Walsh S et al.
2004. Employment and quality of life outcomes among
women with fibromyalgia compared to healthy controls.
Women Health 39(4):1-19. “Employed women report
better quality of life than those not employed, but only for
the physical dimension of quality of life. The
findings regarding MCS [Mental Component Summary Scores] are
intriguing in that women with FMS are not very different
from controls and that employment has little effect on the
mental health component of quality of life.”
Reitinger, A., H.
Radner, H. Tilscher, M. Hanna, A. Windischand W. Feigl. 1996.
[Morphologic study of trigger points.] Manuelle Medizin
Remesar, X., I Rafecas,
J. A. Fernandez-Lopez and M. Alemany. 1997. Is leptin an
insulin counter-regulatory hormone? FEBS Lett
Renan-Ordine R, Alburquerque-Sendi N F, Rodrigues de Souza DP et al. 2011. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 41(2):43-50. A self-stretching program coupled with bodywork on TrPs was far superior to self-stretching alone in the relief of plantar heel pain.
Reuben SS, Reuben SS. 2007.
Chronic pain after surgery: what can we do to prevent it?
Curr Pain Headache Rep. 11(1):5-13. “Effective
preventative analgesic techniques may be useful in reducing
not only acute pain but also chronic postsurgical pain and
disability. This review examines the efficacy of using
a variety of analgesic techniques aimed at preventing or
reducing chronic pain after surgery.”
J. 2002. Current concepts in insulin resistance, type 2
diabetes mellitus, and the metabolic syndrome. Am J Cardiol
90(Suppl 1):19. Insulin resistance plays a critical role in
the development of cardiovascular disease. Nitric
oxide-mediated vasodilation is impaired in insulin resistance.
Insulin resistance may be moderated by the use of insulin
Reyes Del Paso GA, Garrido S, Pulgar A et al. 2011. Autonomic cardiovascular control and responses to experimental pain stimulation in fibromyalgia syndrome. J Psychosom Res. 70(2):125-134. "The data suggest impaired autonomic cardiovascular regulation in FMS in terms of reduced sympathetic and parasympathetic influences, as well as blunted sympathetic reactivity to acute stress. The association between baroreflex function and pain experience reflects the pain inhibition mediated by the baroreceptor system. Given the reduced baroreflex sensitivity in FMS, one may assume deficient ascending pain inhibition arising from the cardiovascular system, which may contribute to the exaggerated pain sensitivity of FMS."
Reyes Del Paso GA, Pulgar A, Duschek S et al. 2011. Cognitive impairment in fibromyalgia syndrome: The impact of cardiovascular regulation, pain, emotional disorders and medication.
Eur J Pain. [Dec 19 Epub ahead of print]. "Thirty-five patients with FMS and 29 matched healthy controls completed a neuropsychological test measuring attention and arithmetic processing. As possible factors underlying the expected cognitive impairment, clinical pain intensity, co-morbid depression and anxiety disorders, sleep complaints, medication use, as well as blood pressure parameters were investigated. The patients' test performance was substantially reduced, particularly in terms of lower speed of cognitive processing and restricted improvement of performance in the course of the task. While the extent of depression, anxiety, fatigue and sleep complaints was unrelated to test performance, better performance was observed in patients showing lower pain ratings and those using opiate medication. The data corroborate the presence of substantial cognitive impairment in FMS. While the experience of chronic pain is crucial in mediating the deficits, co-morbid depression, anxiety, fatigue and sleep complaints play only a subordinate role. In the control group, but not in the patients, blood pressure was inversely associated with mental performance. This finding is in line with the well known cognitive impairment in hypertension. The lack of this association in FMS confirms previous research showing aberrances in the interaction between blood pressure and central nervous function in the affected patients."
1981. Myofascial trigger point syndromes in the practice
of rheumatology. Arch Phys Med Rehabil.
62(3):111-114. “Pain referred from a muscle can mimic both
pain from a joint and radicular pain associated with disease of
spinal joints, leading to mistakes in diagnosis and in
treatment. When articular disease is present, it
predisposes to myofascial trigger point (TP) syndromes.
With arthritis, TPs in muscles may result from decreased
mobility with prolonged shortening of muscles, from abnormal
mechanical stress on muscles and from stimuli arising in
diseased joints. During examination for signs of
myofascial disorders, the numbers of tender points and of local
twitch responses in women with rheumatoid arthritis were twice
those found in women free of any rheumatic illness. It is
important to consider this high frequency of myofascial
syndromes in persons with arthritis when treating pain or
weakness which could be due to the muscles rather than the
joints. Conversely, it has been proposed, on theoretical
and clinical grounds, that muscular TPs can cause joint disease.
This hypothesis has important implications for the treatment of
arthritis.” [Studies are linking TrPs with arthritic
conditions, and have been doing so for some time. They are
going unnoticed. ALL arthritis patients need assessment of
co-existing TrPs to relieve them of unnecessary symptom burden.
Reynolds, M. D. 1984.
Myofascial trigger points in persistent posttraumatic shoulder
pain. South Med J 77(10):1277-1280.
Rha DW, Shin JC, Kim YK et al. 2011. Detecting local twitch responses of myofascial trigger points in the lower back muscles using ultrasonography. Arch Phys Med Rehabil. [Aug 11 Epub ahead of print]. "These findings suggest that ultrasonography was useful for detecting LTRs (local twitch responses) of MTrPs, especially for LTRs in the deep muscles. Ultrasound guidance may improve the therapeutic efficacy of trigger point injection for treating MTrPs in the deep muscles."
Rhodin A, Gronbladh L, Nilsson
LH et al. 2005. Methadone treatment of chronic
non-malignant pain and opioid dependence – A
long-term follow-up. Eur J Pain [Epub
ahead of print June 20] “A structured methadone
program can be used for treating chronic pain
patients with opioid dependence improving pain
relief and quality of life. However, side
effects and serious adverse events may limit the
beneficial effects of the method.”
Rhudy JL, Martin SL, Terry EL et al. 2012. Using multilevel growth curve modeling to examine emotional modulation of temporal summation of pain (TS-pain) and the nociceptive flexion reflex (TS-NFR). Pain. [Aug 21 Epub ahead of print]. "Emotion can modulate pain and spinal nociception, and correlational data suggest that cognitive-emotional processes can facilitate wind-up-like phenomena (i.e., temporal summation of pain)....These results imply that, at least in healthy humans, within-subject changes in emotions do not promote central sensitization via amplification of temporal summation. However, future studies are needed to determine whether these findings generalize to clinical populations (e.g., chronic pain)."
Ribeiro LS, Proietti FA. 2004. Interrelations between
fibromyalgia, thyroid autoantibodies, and depression.
J Rheumatol. 31(10):2036-2040. This study
“...suggests an association between FMS and thyroid
Ribel-Madsen S, Christgau S, Gronemann St et al. 2007.
Urinary markers of altered collagen metabolism in
fibromyalgia patients. Scand J Rheumatol.
36(6):470-477. Altered collagen markers were found in FM
patients, but their significance is unclear.
Ribel-Madsen S, Gronemann ST, Bartels
EM et al. 2005. Collagen structure in skin from
fibromyalgia patients. Int J Tissue React.
27(3):75-82. “There are some differences between the amino
acid composition of skin proteins in fibromyalgia patients
compared with controls. The amount of collagen may be
lower in skin from fibromyalgia patients, and collagen
packing in the endoneurium may be less dense.” [This
research may hold a clue to why the skin of FMS patients
reacts so differently than the skin of healthy people. DJS]
Ricci NA, Aratani MC, Dona F et al. 2010. [A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults.] Rev Bras Fisioter.14(5):361-371. [Portuguese] "The studies included in this review provide evidence for the positive effects of VR (vestibular rehabilitation) in elderly and middle-aged adults with vestibular disturbances."[Vestibular dysfunction is a frequent co-existing condition in patients with FM and CMP. DJS]
Rich BA. 1997. A legacy of
silence: bioethics and the culture of pain. J
Med Humanit. 18(4):233-259. “This article takes
bioethicists to task for failing to recognize the
undertreatment of pain as a major ethical, and not
merely a clinical, failing of the medical profession.”
Yet “for over 20 years the medical literature has
carefully documented the undertreatment of all types of
pain by physicians.” [At last, it is not just the
patients who are asking why. DJS]
Rich BA. 1997. A legacy of
silence: bioethics and the culture of pain. J Med
Humanit. 18(4):233-259. “For over 20 years the
medical literature has carefully documented the
undertreatment of all types of pain by physicians.
During this same period, as the field of bioethics came of
age, the phenomenon of undertreated pain received almost no
attention from the bioethics literature. This article
takes bioethicists to task for failing to recognize the
undertreatment of pain as a major ethical, and not merely a
clinical, failing of the medical profession. The
factors contributing to undertreated pain in the clinical
setting are considered, as well as the hazards posed by
recent failures to address ethically questionable clinical
Richards JR, Richards IN, Ozery G et al. 2010. Droperidol Analgesia for Opioid-Tolerant Patients. J Emerg Med. [Sep 10 Epub ahead of print]. "Patients with acute and chronic pain syndromes such as migraine headache, fibromyalgia, and sickle cell disease represent a significant portion of emergency department (ED) visits. Certain patients may have tolerance to opioid analgesics and often require large doses and prolonged time in the ED to achieve satisfactory pain mitigation. Droperidol is a unique drug that has been successfully used not only as an analgesic adjuvant for the past 30 years, but also for treatment of nausea/vomiting, psychosis, agitation, sedation, and vertigo....Droperidol has myriad pharmacologic properties that may explain its efficacy as an analgesic, including: histamine antagonist, muscarinic and nicotinic cholinergic antagonist, anticholinesterase activity, sodium channel blockade similar to lidocaine, and ...opiate receptor potentiation.....Droperidol is an important adjuvant for patients who are tolerant to opioid analgesics."
Richardson K, Gonzalez Y, Crow H et al. 2012. The effect of oral motor exercises on patients with myofascial pain of masticatory system. Case series report. NY State Dent J. 78(1):32-37. "The following case series report explores the impact of oral motor exercises on the management of myofascial pain when used in conjunction with other treatment modalities. Oral motor exercises are used by speech-language pathologists to improve the strength, range of movement and coordination of the oral musculature during non-speech movements. The findings of this case series report suggest an opportunity exists for collaboration between speech-language pathologists and the 'traditional' TMD team." [It will be a new world when the speech-language pathologists discover TrPs. DJS]
Rico-Villademoros F, Calandre EP, Rodriguez-Lopez CM et al. Sexual functioning in women and men with fibromyalgia. J Sex Med. [Oct 24 Epub ahead of print]. "Our results show that sexual dysfunction is common in patients with fibromyalgia. The disease seems to deeply affect all dimensions of sexual functioning in both females and males." [Since myofascial TrPs occur in patients with FM, and these patients were not assessed for pelvic floor and other TrPs that can cause sexual dysfunction, it is suspected that at least the majority of these symptoms could be caused by co-existing TrPs. DJS]
Ridgway, K. 1999.
Acupuncture as a treatment modality for back problems. Vet
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and G. Neeck. 1998. Secretory pattern of GH, TSH, thyroid
hormones, ACTH, cortisol, FSH, and LH in patients with
fibromyalgia syndrome following systemic injection of the
relevant hypothalamic-releasing hormones. Z Rheumatol
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Riemann BL, Lephart SM. 2002. The
sensorimotor system, part II: the role of proprioception in
motor control and functional joint stability. J
Athl Train. 37(1):80-84. “Although controversy remains
over the precise contributions of specific mechanoreceptors,
proprioception as a whole is an essential component to
controlling activation of the dynamic restraints and motor
Riering K, Rewerts C, Zieglgansberger
W. 2004. Analgesic effects of 5-HT3 receptor
antagonists. Scand J Rheumatol Suppl. (119):19-23.
Tropisetron and other selective 5-HT3 receptor antagonists
have promise in the treatment of FMS.
Rigaud J, Delavierre D, Sibert L et al. 2010. [General principles of the diagnostic approach to chronic postoperative pelvic and perineal pain.] Prog Urol 20(12:1139-1144.[French] "The aetieological and diagnostic assessment of chronic postoperative pelvic and perineal pain requires a detailed clinical analysis based on examination of the scars and analysis of the clinical signs of muscle and nerve lesions..... A test block of a nerve or trigger point is the main test performed to determine the level of the lesion responsible for pain. " [Trigger points again as the pain generator. When will the medical world get it? DJS]
Rigaud J, Delavierre D, Sibert L et al. 2010. [Management of chronic pelvic and perineal pain after suburethral tape placement for urinary incontinence.] Prog Urol. 20(12):1166-1174. [French] The role of suburethral tape in the pathogenesis of pain is essentially based on the fact that pain occurs immediately or over the days following (suburethral surgical) tape placement. The clinical features are usually fairly nonspecific, with pelvic myofascial pain, possibly associated with direct or indirect nerve lesions (obturator nerve or pudendal nerve). Local infiltration of anaesthetic along the tape is performed for diagnostic purposes to confirm the aetiology of the pain and can also have a temporary therapeutic efficacy. Surgical removal of the tape was performed with satisfactory intermediate-term results in about two out of three cases....The frequency of chronic pelvic and perineal pain following suburethral tape placement appears to be underestimated. The diagnostic approach is based on complete clinical examination and infiltration along the tape and any nerves involved. Surgical removal of the tape provides the best intermediate-term analgesic results."
DA, Gelabert H. 2009. The management of thoracic
outlet syndrome in teenaged patients. Ann Vasc Surg.
23(3):335-340. A significant number of teenaged patients
with thoracic outlet syndrome can be helped by TrP injection
and other TrP therapy. [Much surgery can be prevented
if TRP therapy and control of perpetuating factors is done
promptly and thoroughly. DJS]
Riley GP, Harrall RL, Constant CR et
al. 1996. Prevalence and possible pathological
significance of calcium phosphate salt accumulation in
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Eberlein-Konig and H. Behrendt. 1999. "Eco-syndrome"
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Rios R, Zautra AJ. 2011. Socioeconomic disparities in pain: the role of economic hardship and daily financial worry. Health Psychol. 30(1):58-66. "Economic hardship was associated not only with greater exposure to daily financial worries but also with greater vulnerability to pain on days when daily financial worries were experienced."
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et al. 2005. Proprioception, gain kinematics, and rate
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impairs insulin secretion and causes insulin resistance. J
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Diego, M. Trinchet and A. Garcia Monforte. 1997.
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Rivera J, Rejas J,
J et al. 2009. Resource
utilization and health care costs in patients diagnosed with
fibromyalgia in Spain. Clin
Exp Rheumatol. 27(5 Suppl 56):S39-45. “Fibromyalgia (FM)
patients have been regarded as great utilizers of health
resources, with important related costs. The aim of this study
is to describe health care resource utilization and related
costs of FM from the perspective of the National Health System
in Spain….During the year 2006 the mean total cost per patient
per year was 9,982 Euros, of which 3,245.8 (32.5%) corresponded
to health care costs and 6,736.2 (67.5%) to indirect costs
attributable to productivity losses. Non-drug therapies
accounted for the largest proportion of the health care costs,
three times greater than the drug treatment. Patients with
higher total costs showed the greatest disease involvement. The
variables associated to the total health care costs were
functional capacity, depression, comorbidities and age. Patients
with permanent working disability were the greatest resource
utilizers….. FM patients with higher costs show the greatest
disease involvement. Direct and indirect costs are well
correlated to disease severity. The indirect costs account for
most of the economic burden of FM and approximately double the
health care costs. Patients with permanent working disability
present more severe disease and generate greater health care
Rivera J, Rejas-Gutiérrez J, Vallejo MA et al. 2012. Prospective study of the use of healthcare resources and economic costs in patients with fibromyalgia after treatment in routine medical practice. Clin Exp Rheumatol. [Aug 4 Epub ahead of print]. "Treated patients with FM in daily practice improved their clinical status and were accompanied by a significant reduction in the cost of the illness. The extra cost of drugs is substantially compensated for by less use of other healthcare resources and fewer days off work."
Rivera J, Vallejo MA, Esteve-Vives J. 2012. Drug prescription strategies in the treatment of patients with fibromyalgia. Reumatol Clin. [May 17 Epub ahead of print]. [Article in English, Spanish]. "The introduction of anticonvulsants or antidepressants, in an isolated or combined form, produces a significant clinical improvement in FM patients. The most effective drug strategy is the introduction of both drugs at the same time. The least effective strategy is not to change the number of drug prescriptions."
2001. The neurophysiology of myofascial pain syndrome.
Curr Pain Headache Rep. 5(5):432-440.
Roach S, Sorenson E, Headley B et al. 2012. The prevalence of myofascial trigger points in the hip in patellofemoral pain patients. Arch Phys Med Rehabil Nov 2 [Epub ahead of print] Patients with pain in the front of the knee have a much greater prevalence of trigger points bilaterally in the gluteus medius and quadratus lumborum muscles. They also had less hip abduction strength which TrP release therapy was not sufficient to increase.
Robbins, W. R., P. S.
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Roberts, B. L. 1997.
Soft tissue manipulation: neuromuscular and muscle energy
techniques. J Neurosci Nurs 29(2):123-7.
Roberts, T. B. 1999.
Do entheogen-induced mystical experiences boost the immune
system? Psychedelics, peak experiences, and wellness. Adv
Mind Body Med 15(2):139-47.
de Senna B, Marques LS, Franca JP et al. 2009.
Condyle-disk-fossa position and relationship to clinical signs
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Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
Robinson ME, Craggs JG, Price DD et al. 2010. Gray Matter Volumes of Pain-Related Brain Areas are Decreased in Fibromyalgia Syndrome. J Pain. [Dec 9 Epub ahead of print].
"Fibromyalgia (FM) is a chronic, widespread musculoskeletal pain disorder that is very prevalent in the general population (approximately 5%). Accumulating evidence suggests that FM is associated with central pain processing abnormalities, i.e., central sensitization. Several previous studies of chronic pain patients, including FM, have shown gray matter atrophy of brain areas associated with sensory and affective pain processing. These findings, however, have not been confirmed in all FM studies. In this study, we investigated gray matter volumes of brain areas associated with pain-related areas of FM patients identified by functional brain imaging….
Using a more stringent analysis than other VBM (voxel-based morphometric) studies, we provide evidence for decreased gray matter volumes in a number of pain-related brain areas in FM. Although the mechanisms for these gray matter changes are presently unclear, they may contribute to some of the core features of this chronic disorder including affective disturbances and chronic widespread pain….Increasing evidence supports the association of chronic pain with accelerated gray matter atrophy in pain disorders like low back pain, IBS, and FM syndrome. However, cause-effect relationships between chronic pain and decreased gray matter volumes have not been established yet and will require future prospective studies."
Robinson RL, Kroenke K, Williams DA et al. 2013. Longitudinal observation of treatment patterns and outcomes for patients with fibromyalgia: 12-month findings from the REFLECTIONS study. Pain Med. [June 11 Epub ahead of print]. This was a study using data from 1700 patients based on subjective inventories by patients on pregabalin (12%) duloxetine (15.5%), minilcipran (7.9%) or tricyclic antidepressants (3.9%). The focus was on "unique drugs for fibromyalgia" with over 75% of the patients taking over two or more medications, but not necessarily those medications. Duloxene and minilcipran patients had fewer outpatient visits than the others, and patients reported satisfaction with their treatment and "their fibromyalgia medication". [Bold lettering is theirs.] In the conclusions, ALL of the fibromyalgia patients had "modest improvements, high resources, and medication use, and were satisfied with the care they received." Authors admitted that it was difficult to tell the difference among the groups of patients due to the "high rates of drub discontinuation and concomitant medication over the 12 month period" of the study. The study was financed by Eli Lilly and Company. [This study is included in annotated references because it is easy to see how it could be misconstrued and perhaps misused. When quoting studies, often the sponsors of the studies and their relation to the medications are not given. DJS]
Robinson RLS, Jones ML. 2006.
In search of pharmacoeconomic evaluation for
fibromyalgia treatments: a review. Expert Opin
Pharmacother. 7(8):1027-1039. This article mentions
the significant disability, complexity and economic
costs of FMS, and stresses the lack of cost/benefit
medical studies on remedies for FMS and that patients
may try “...multiple pharmacological and
non-pharmacological therapies with questionable
efficacy.” One must take into consideration any
biases, intentional or unintentional, built in to
research articles, but readers may not always be aware
of the source of the research. This paper was
financed by a pharmaceutical company and written by its
R., A. Castonguy, I. Rousse et al. 2002. Glial cells are
determinant of synaptic activity. Glia (Suppl
1):S9 [Abstract]. This research indicates “that
perisynaptic glial cells modulate sybaptic efficacy in a
frequent dependent manner.
Rocca, P. V. 1999.
Fibromyalgia: how disabling? Del Med Jrl 71(6): 263-5.
Rocha CB, Sanchez TG. 2012. [Efficacy of myofascial trigger point deactivation for tinnitus control] [Portuguese] Braz J Otorhinolaryngol 78(6):21-26. "Besides medical and audiological investigation, patients with tinnitus should also be checked for: 1) presence of myofascial pain surrounding the ear; 2) laterality between both symptoms; 3) initial decrease of tinnitus during muscle palpation. Treating this specific subgroup of tinnitus patients with myofascial trigger point release may provide better results than others described so far. [There must also be an understanding that bilateral TrPs can be interacting with tinnitus, and that TrPs in the areas of the neck and surrounding tissues may also contribute to tinnitus. DJS]
Rocha CA, Sanchez TG. 2007.
Myofascial trigger points: another way of modulating tinnitus.
Prog Brain Res. 166:209-214. “Tinnitus is a
multifaceted symptom that may have many causes…” “Tinnitus
can often be modulated by different kinds of stimuli.” “In
56% of patients with tinnitus and MTPs, the tinnitus could be
modulated by applying digital compression of such points, mainly
those of the masseter muscle.” “Compression of MTPs was
most effective in patients who have had chronic pain earlier in
the examined areas.” [As tinnitus can be severe enough to
cause suicidal ideation, disrupting lives significantly, it is
ironic that some patients can be helped so easily, yet are not.
Roche, H. M. 1999.
Dietary carbohydrates and triacylglycerol metabolism. Proc
Rodero B, Casanueva B, Garcia-Campayo J et al. 2010. Stages of chronicity in fibromyalgia and pain catastrophising: a cross-sectional study. BMC Musculoskel Disord. 11(1):251. "Fibromyalgia (FM) is a prevalent and disabling disorder characterized by widespread pain and other symptoms such as insomnia, fatigue and depression.... The present research examined the relationship among pain, catastrophic thinking and FM impact, as a function of stage of chronicity.... These findings provide preliminary evidence that stage of chronicity is an important moderator of psychological vulnerability for FM impact and should be taken into account by tailoring psychological interventions." [One can always tell when the researchers are psychologist and/or psychiatrists. The researchers must address the myofascial trigger points causing the symptoms and maintaining central sensitization. The lack of myofascial training in medical community is the greatest catastrophe of all. DJS]
qualitative exploration of carers' and 'patients'
experiences of fibromyalgia: one illness, different
Musculoskeletal Care. [Mar 15 Epub ahead of print].
“This study aimed to explore the lived experiences of both
those with FMS and their spousal carers…. . An overriding
theme running throughout was loss of identity, which fed
into a sense of isolation. Participants reported feeling
isolated from: healthcare professionals, whom they felt they
had to convince that they had something 'real', and from
friends and family because the unpredictability of their
symptoms meant that they were less able to plan ahead and
often had to pull out of arranged outings. They also felt
isolated from their identity because they no longer
recognized the person that they once were, and struggled to
recognize the person that they had become. As a consequence,
the people with FMS and their carers were both engaged in a
process of reassessing who they were, now that FMS had
become such a large part of their lives. This sense of
isolation was evidenced for the carers as well as the people
Ibanez-Bosch R, Portero-Vasquez A et al. 2009. Cognitive
impairment in patients with fibromyalgia syndrome as assessed by
the Mini-Mental State Examination. BMC Musculoskeletal
Disord. 10(1):162. “Compared with the population
reference value, patients with FMS showed high frequency of
MA, Afari N, Buchwald DS. 2009. Evidence for overlap
between urological and noneurological unexplained clinical
conditions. J Urol. 182(5):2123-2131. “The
literature suggests considerable comorbidity between urological
and noneurological unexplained clinical conditions. The
most robust evidence for overlap was for irritable bowel
syndrome and urological unexplained syndromes with some
estimates of up to 79% comorbidity between chronic pelvic pain
and symptoms of irritable bowel syndrome.” [Unfortunately,
myofascial pain was not considered in this article, and much of
the FM-relationship could be from co-existing myofascial TrPs.
Other research certainly indicates that the pelvic symptoms stem
from co-existing TrPs and not from FM, which highlights the
dangers of ignoring the contributions of the TrPs as well as the
TrPs themselves. DJS]
Rodriguez EM, Blazquez JL, Pastor FE
et al. 2005. Hypothalamic tanycytes: a key component
of brain-endocrine interaction. Int Rev Cytol.
247:89-164. “Tanycytes are bipolar cells bridging the
cerebrospinal fluid (CSF) to the portal capillaries and may
link the CSF to neuroendocrine events. During the
perinatal period a subpopulation of radial glial cells
differentiates into tanycytes...” There are four
populations of tanycytes, and each subtype expresses
important “...functional molecules, such as glucose and
glutamate transpoters; a series of receptors for
neuropeptide and peripheral hormones; secretory molecules
such as transforming growth factors, prostaglandin E(2), and
the specific protein P85; and proteins of the endocytic
pathways.” “The discovery in tanycytes of new
functional molecules is opening a new field of research.
Thus, thyroxine deiodinase type II, an enzyme generating
triiodothyronine T(3) from thyroxine, appears to be
exclusively expressed by tanycytes, suggesting that these
cells are the main source of brain T(3).” [Other types
of tanycytes are involved in glucose, and the patients who
are thyroid resistant also seem to be insulin resistant.
This may be a clue to why some FMS patients are T4-resistant
and insulin resistant. DJS]
Rodriguez-Fernandez AL, Garrido-Santofimia V, Gueita-Rodriguez J et al. 2011. Effects of burst-type transcutaneous electrical nerve stimulation on cervical range of motion and latent myofascial trigger point pain sensitivity. Arch Phys Med Rehabil. 92(9):1353-1358. "A 10-minute application of burst-type TENS (transcutaneous electrical nerve stimulation) increases in a small but statistically significant manner the RPPT (referred pressure pain threshold) over upper trapezius latent MTrPs and the ipsilateral cervical range of motion."
2009. Does effective management of sleep disorders improve
pain symptoms? Drugs. 69 Suppl 2:5-11. “Co-morbid
insomnia is a much more frequent problem than primary
insomnia. In co-morbid insomnia, management of the
underlying disease can improve sleep difficulty. Conversely,
treating the sleep disorder may also improve the co-morbid
condition. For example, patients with painful chronic
illnesses are more likely to experience sleep disturbance
than patients with non-painful illnesses. Moreover, there is
evidence that insomnia further exacerbates pain in these
illnesses. This suggests that a reciprocal relationship
exists between pain and sleep, and that intervention
targeted primarily at insomnia may improve pain. Treatment
options for sleep disorders in the context of pain that have
been assessed include cognitive behavioral therapy for
insomnia and various pharmacological therapies. In
randomized clinical trials, cognitive behavioral therapy
significantly improved insomnia secondary to chronic pain
compared with control therapy, but pain was only improved in
patients in whom it was associated with pain disorders other
than fibromyalgia. Of the pharmacological agents studied (zopiclone,
zolpidem and triazolam), only triazolam improved both sleep
and pain to a greater extent than placebo. Overall, clinical
data supporting a cause-effect relationship between insomnia
and pain are preliminary and are limited to several small
trials. Further investigation is required to clarify the
extent of the link between insomnia and pain and whether
successfully managing insomnia secondary to pain improves
pain symptoms. Areas of particular interest include
investigation of the effect of sleep agents on analgesia and
the effect of analgesics on sleep.”
Roehrs T, Diederichs C, Gillis M et al. 2012. Nocturnal sleep, daytime sleepiness and fatigue in fibromyalgia patients compared to rheumatoid arthritis patients and healthy controls: A preliminary study. Sleep Med. [Nov 10 Epub ahead of print]. "Women with FM have similar nocturnal sleep disturbance as those with RA (rheumatoid arthritis), but FM patients report greater self-rated daytime sleepiness and fatigue than RA and HC, which did not correspond to the relatively low level of objectively determined daytime sleepiness of FM patients. These findings suggest a generalized hyperarousal state in FM."
Roehrs T, Hyde M, Blaisdell B et al.
2006. Sleep loss and REM sleep loss are hyperalgesic.
Sleep. 29(2):145-151. “...the loss of four hours of
sleep and specific REM sleep loss are hyperalgesic the
following day. Pharmacologic treatments and clinical
conditions that reduce sleep and REM sleep time may increase
Roth T. 2005. Sleep and pain: interaction of two vital
functions. Semin Neurol 25(1):106-116. “The
pain sleep nexus has been modeled in healthy pain-free subjects
and the studies have demonstrated the bidirectionality of the
sleep-pain relation. ...treatment must focus on
alleviation of both the pain and sleep disturbance.”
Roelofs J, Sluiter JK, Frings-Dresen MH
et al. 2007. Fear of movement and (re)injury in chronic
musculoskeletal pain: evidence for an invariant two-factor model
of the Tampa Scale for Kinesiophobia across pain diagnoses and
Dutch, Swedish and Canadian samples. Pain. [Feb 19
Epub ahead of print] [This study does not take into
consideration that restriction of movement may be due to
co-existing myofascial trigger points that cause pain at the end
of range of motion. Until psychologists, psychiatrists, and
indeed all health care professionals are trained in the
awareness of myofascial medicine, papers like this will be, at
best, incomplete, and, at worst, lead to erroneous conclusions.
Rogers, N., C. van den
Heuvel, and D. Dawson. 1997. Effect of melatonin and
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J Pineal Res 22(2): 75-80.
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Floor Dysfunct [Epub ahead of print] Retrospective chart
review of vaginal diazepam suppository in high-tone pelvic
floor dysfunction. Diazepam suppositories can be a helpful
accessory treatment for tight pelvic floor muscles. [This
supports use of topical diazepam or carisoprodol used inside
the vagina and/or rectum as an adjunct treatment for pelvic
floor muscles tightened by TrPs. DJS]
Rogge N. 2003. [Generalized
muscle pain in a 67-year-old patient. Myalgia/myogitis
in therapy with Zocor] Schweiz Rundsch Med Prax.
Rogozhin AA, Devlikamova FI. 2007.
Inactivation of trigger points could significantly reduce
radicular pain. J Musculoskel Pain 15 (Supp
13):35 item 59. [Myopain 2007 Poster] “It is
difficult to distinguish between radicular and MPS because
trigger points [TrPs] are widely present in patients with
radiculopathy.” “We can suppose that radicular pain in
patients with acute radiculopathy partly could be caused by
activation of TrPs. Inactivation of TrPs in patients
with radiculopathy never leads to complete pain relief but
could be useful in patients with prolonged time course of
disease.” [The patient must be treated, rather than
the radiography. This means that soft tissue problems
such as MTPs must be treated rather than the current focus
on the skeletal system and discs alone. DJS.]
Roizenblatt S, Fregni F, Gimenez R et
al. 2007. Site-specific effects of transcranial direct
current stimulation on sleep and pain in fibromyalgia: a
randomized, sham-controlled study. Pain Pract.
7(4):297-306. “Our findings suggest that one possible
mechanism to explain the therapeutic effects of tDCS in
fibromyalgia is via sleep modulation that is specific to
modulation of primary M1 (motor cortex) activity.”
Roizenblatt, S., S.
Tufik, J. Goldenberg, L. R. Pinto, M. P. Hilario and D.
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Pentoxifylline may be helpful in some channelopathies.
Romanello S, Spiri D, Mancuzzi E et al. 2013 Association between childhood migraine and history of infantile colic. JAMA. 309(15):1607-1612. Infant with colic have a grater chance of developing migraines between 6 and 18 years old. The association between these types of pain is yet unknown to these researchers. [Janet Travell long ago documented that trigger points causing colic can be relieved by vapocoolant spray, and other researchers have documented the connection of trigger point cause or contribution to migraines. The great Czech doctor Karel Lewit MD has observed that colic is an early indication that trigger points will develop later, and that migraines (and menstrual pain) are adolescent signs that trigger points will be part of the diagnoses. Perhaps that is the connection for which these researchers search, and perhaps early detection and treatment of the TrPs would prevent chronic myofascial pain from developing. It certainly would be worth trying. DJS]
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Rooks DS. 2007. Fibromyalgia
treatment update. Curr Opin Rheumatol. 19(2):111-117.
“Treatment goals should include the improvement of symptoms,
primarily pain and sleep, and the promotion of positive health
behaviors with the aim of improving physical function and
Roosink M, Renzenbrink GJ, Buitenweg JR et al. 2010. Somatosensory Symptoms and Signs and Conditioned Pain Modulation in Chronic Post-Stroke Shoulder Pain. J Pain. [Dec 16 Epub ahead of print]. "Persistent shoulder pain is a common complication after stroke. Its etiology and underlying mechanisms are not well understood and treatment is generally unsatisfactory. The objective of this study was to assess the role of central sensitization and disinhibition in chronic stroke patients with chronic PSSP (n = 19), pain-free stroke patients (n = 29), and healthy controls (n = 23)….. Sensory abnormalities were more frequently observed and more severe in patients with PSSP, including positive signs such as allodynia at the affected side and generalized hyperalgesia at the unaffected side. CPM was similar in stroke patients and healthy controls. This study showed that chronic PSSP was associated with several positive and negative somatosensory signs, implicating a role for central sensitization and possibly for disinhibition. Since the causal relationship remains unclear, and may be related to either neuroplasticity induced by ongoing nociception as well as to the neuropathic brain lesion, prospective studies are warranted….The assessment of somatosensory symptoms and signs and endogenous pain modulation demonstrated a role for central sensitization and possibly for disinhibition in chronic PSSP. Prevention and treatment of PSSP could benefit from a more detailed analysis of both peripheral and central pain mechanisms." [It would be interesting to check these patients for those TrPs that cause shoulder pain. It is very likely that there are treatable myofascial components to post-stroke pain. DJS]
Roost M, Nilsson P. 2002. [Sleep
disorders — a public health problem. Potential risk
factor in the development of type 2 diabetes, hypertension,
dyslipidemia and premature aging] Lakartidningen
99(3):154-157. [Swedish] “Sleep disorders may play a
primary role in the pathophysiology of cardiovascular
disease. This has recently been documented in
association with metabolic disturbances and impaired insulin
action following experimental sleep deprivation. Sleep
disorders may finally prove to be part of the
pathophysiological chain linking adverse psychosocial stress
with the metabolic syndrome, and ultimately premature aging
and early mortality.”
Rosado-Pérez J, Santiago-Osorio E, Ortiz R et al. 2012. Tai chi diminishes oxidative stress in Mexican older adults. J Nutr Health Aging. 16(7):642-646. "...the daily practice of Tai Chi is useful for reducing OxS (oxidative stress) in healthy older adults."
TY. 2009. Musculoskeletal pain and sexual function in
women. J Sex Med. [Sep 14 Epub ahead of print]
“Musculoskeletal pain (MP) that is not essentially genitally
based often interferes with sex as well yet is not
considered a distinct sexual dysfunction. MP is
generally addressed by physiatrists, orthopedists, and
rheumatologists who are not traditionally trained in sexual
medicine, and therefore, the sexual concerns of women with
MP often go unaddressed.” “Lack of mobility and MP can
restrict intercourse and limit sexual activity, and gender
differences are noted in response to pain. Sexual and
relationship counseling should be offered as a component of
rehabilitative treatment. Physical therapists are
uniquely qualified to provide treatment to address
functional activities of daily living, including sexual
intercourse, and offer advice for modifications in
Rosenbaum TY. 2009.
Musculoskeletal pain and sexual function in women.
J Sex Med. [Sep 14 Epub ahead of print]. “Lack of
mobility and MP (musculoskeletal pain) can restrict
intercourse and limit sexual activity, and gender
differences are noted in response to pain. Sexual and
relationship counseling should be offered as a component of
rehabilitative treatment. Physical therapists are
uniquely qualified to provide treatment to address
functional activities of daily living, including sexual
intercourse, and offer advice for modifications in
positioning.” [Future studies will be greatly enhanced
if myofascial trigger point assessment and remediation would
be included. DJS]
Rosenblum A, Joseph H, Fong C et al.
2003. Prevalence and characteristics of chronic pain
among chemically dependent patients in methadone maintenance
and residential treatment facilities. JAMA
289(18):2370-2378. “Chronic severe pain is prevalent
among patients in substance abuse treatment, especially MMTP
patients. Pain is associated with functional
impairment and correlates of pain vary with the population.
Substance abuse treatment programs need to develop
comprehensive and structured pain management programs.”
Rosengren SM, Colebatch JG. 2010. Vestibular evoked myogenic potentials are intact in cervical dystonia. Mov Disord. [Oct 19 Epub ahead of print]. "Vestibular dysfunction has been reported in patients with cervical dystonia (CD), but it is still unclear whether the abnormalities occur as part of the CD syndrome or whether they arise from the abnormal posture and movement of the head..... Both cervical and ocular VEMPs (vestibular-evoked myogenic potentials) were present in the majority of patients and controls..... Our results showed that VEMPs can be reliably recorded from both the neck and extraocular muscles in patients with CD, even after long disease or treatment durations, and provide evidence for intact short-latency vestibular reflexes in CD. " [FM, TrPs and vestibular dysfunction ar often interactive co-existing conditions. DJS]
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Epub ahead of print]. “Chronic stress is a major health
concern, often leading to depression, anxiety, or when
severe enough, posttraumatic stress disorder. While many
studies demonstrate that the amygdala is hyperresponsive in
patients with these disorders, the cellular
neurophysiological effects of chronic stress on the systems
that underlie psychiatric disorders, such as the amygdala,
are relatively unknown.... These data demonstrate a specific
channelopathy that occurs in the amygdala (in rats) after
chronic stress. This enhanced excitability of amygdala
neurons after chronic stress may explain the observed
hyperresponsiveness of the amygdala in patients with
posttraumatic stress disorder and may facilitate the
emergence of depression or anxiety in other patients.” [This
study is of interest in that chronic stress can initiate
TrPs, and TrPs may of themselves be a calcium channelopathy.
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contained not only sophisticated medical language but
multisyllable, nonmedical terms and vocabulary not used in
typical everyday conversation.” Opioid contracts must be
understandable and clear, and this is not the case.
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for those components which may be theoretically involved in
proprioceptive afferent elaboration. These changes are
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Contractured, painful muscles can cause early sensory
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mechanism of proprioception dysfunction in myofascial TrPs.
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providing improvement in pain as well as the general and mental
health of these patients.”
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Roussel NA, Nijs J, Meeus M et al. 2013. Central Sensitization and Altered Central Pain Processing in Chronic Low Back Pain: Fact or Myth? Clin J Pain. 29(7):625-638. "Results of studies examining the responsiveness to various stimuli in patients with chronic LBP (low back pain) are conflicting. Some studies in patients with chronic LBP have demonstrated exaggerated pain responses after sensory stimulation of locations outside the painful region, while other studies report no differences between patients and healthy subjects. Studies examining the integrity of the endogenous pain inhibitory systems report unaltered activity of this descending inhibitory system. In contrast, studies analyzing brain structure and function in relation to (experimentally induced) pain provide preliminary evidence for altered central nociceptive processing in patients with chronic LBP. Finally, also psychosocial characteristics, such as inappropriate beliefs about pain, pain catastrophizing, and/or depression may contribute to the mechanisms of central sensitization. …It tempting to speculate that ongoing nociception is associated with cortical and subcortical reorganization and may play an important role in the process of the chronification of LBP. Future prospective research should explore to what extent these changes are reversible and if this reversibility is associated with improved functioning of patients."
Roussou E, Ciurtin C. 2012. Clinical overlap between fibromyalgia tender points and enthesitis sites in patients with spondyloarthritis who present with inflammatory back pain. Clin Exp Rheumatol. [Aug 30 Epub ahead of print]. "To assess the extent of coexistence of inflammatory back pain (IBP) with fibromyalgia (FM) features in patients with spondyloarthritis (SpA), and to assess the degree of overlap of FM tender points (TeP) and enthesitis sites (ES) in patients with SpA.....One third of patients with IBP fulfilled the criteria for FM. There is a significant degree of overlap between FM TeP and ES in patients with IBP.[Since many patients with FM have trigger points, and trigger points in the attachment areas cause enthesitis and enthesis, it would be helpful to know what percentage of these patients had TrPs and if the contracture from TrPs might cause the inflammation. DJS]
Rowbotham MC, Twilling L, Davies P et
al. 2003. Oral opioid therapy for chronic peripheral
and central neuropathic pain. New England Jour Med
Rowe PC, Fontaine KR, Violand RL. 2013. Neuromuscular strain as a contributor to cognitive and other symptoms in chronic fatigue syndrome: hypothesis and conceptual model. Front Physiol. 4:115. "Individuals with chronic fatigue syndrome (CFS) have heightened sensitivity and increased symptoms following various physiologic challenges, such as orthostatic stress, physical exercise, and cognitive challenges. Similar heightened sensitivity to the same stressors in fibromyalgia (FM) has led investigators to propose that these findings reflect a state of central sensitivity. A large body of evidence supports the concept of central sensitivity in FM. A more modest literature provides partial support for this model in CFS, particularly with regard to pain. Nonetheless, fatigue and cognitive dysfunction have not been explained by the central sensitivity data thus far. Peripheral factors have attracted attention recently as contributors to central sensitivity. Work by Brieg, Sunderland, and others has emphasized the ability of the nervous system to undergo accommodative changes in length in response to the range of limb and trunk movements carried out during daily activity. If that ability to elongate is impaired-due to movement restrictions in tissues adjacent to nerves, or due to swelling or adhesions within the nerve itself-the result is an increase in mechanical tension within the nerve. This adverse neural tension, also termed neurodynamic dysfunction, is thought to contribute to pain and other symptoms through a variety of mechanisms. These include mechanical sensitization and altered nociceptive signaling, altered proprioception, adverse patterns of muscle recruitment and force of muscle contraction, reduced intra-neural blood flow, and release of inflammatory neuropeptides. Because it is not possible to differentiate completely between adverse neural tension and strain in muscles, fascia, and other soft tissues, we use the more general term "neuromuscular strain." In our clinical work, we have found that neuromuscular restrictions are common in CFS, and that many symptoms of CFS can be reproduced by selectively adding neuromuscular strain during the examination. In this paper we submit that neuromuscular strain is a previously unappreciated peripheral source of sensitizing input to the nervous system, and that it contributes to the pathogenesis of CFS symptoms, including cognitive dysfunction." [This is an interesting paper indicating that perhaps trigger points may be common in CFS, as they are in FM. DJS]
Roy-Byrne P, Smith WR, Goldberg
J et al. 2004. Post-traumatic stress disorder among patients with chronic pain and chronic fatigue.
Psychol Med 34(2):363-368. "Optimal clinical care for patients with FMS should include an assessment of trauma in general, and PTSD in
Rra ML, Angst F, Beck T et al. 2012. Horticultural therapy for patients with chronic musculoskeletal pain: results of a pilot study. Altern Ther Health Med. 18(2):44-50. "Seventy-nine patients with chronic musculoskeletal pain (fibromyalgia or chronic, nonspecific back pain) participated in the study….The addition of horticultural therapy to a pain management program improved participants' physical and mental health and their coping ability with respect to chronic musculoskeletal pain."
Rubenstein, S. 1990.
The osteopathy alternative. East West Dec:45-49.
2002. The biofield hypothesis: its biophysical basis and
role in medicine. J Altern Complement Med 8(6):703-717.
“This paper provides a scientific foundation for the
biofield: the complex extremely weak electromagnetic field of
the organism hypothesized to involve electromagnetic
bioinformation for regulating homeodynamics.” This
hypothesis may relate to the benefits of acupuncture,
bioelectromagnetic and other complementary medicine methods.
NJ. 2003. Evaluation of treatments for myofascial pain
syndrome and fibromyalgia. Curr Pain Headache Rep
7(6):433-442. As the title suggests, this is a general
evaluation of these conditions, although the author mentions
early that there is a question of whether either of these
conditions exist. Treatment options are discussed without
mention of perpetuating factors, and they often are the chief
clue to the tailoring of specific remedial work and treatment
is taken to note that treatments must be carefully tailored to
the needs of the individual patient. What is effective
for some may not fill the needs of others, and some types of
therapies require specific attention to protocol for success,
and as the author states, no single therapeutic regimen will
be successful on every patient.
There are many fine points to this article, but it is
unfortunate that the difference between hypothyroid and
thyroid-resistant states was not specified, and that the
dismissal of guaifenesin was based on a single flawed study.
Ruhl A. 2005. Glial cells in the gut.
Neurogastroenterol Motil. 17(6):777-790. “The enteric
nervous system is composed of both neurons and glia.
Recent evidence indicates that enteric glia—which vastly
outnumber enteric neurons—are actively involved in the control
of gastrointestinal functions: they contain neurotransmitter
precursors, have the machinery for uptake and degradation of
neuroligands, and express neurotransmitter-receptors which makes
them well suited as intermediaries in enteric neurotransmission
and information processing in the ENS. Novel data further
suggest that enteric glia have an important role in maintaining
the integrity of the mucosal barrier of the gut. Finally,
enteric glia may also serve as a link between the nervous and
immune systems of the gut as indicated by their potential to
synthesize cytokines, present antigen and respond to
inflammatory insults.” “...it is predictable that enteric glia
are involved in the etiopathogenesis of various pathological
processes in the gut.”
Ruiz Moral R, Rodriguez Salvador J,
Perula L et al. 2006. [Problems and solutions in
health care for chronic diseases. A qualitative study with
patients and doctors.] Aten Primaria 38(9):483-489.
[Spanish] “To tackle prevalent chronic problems
requires, in the view of doctors and patients, important
modifications that are related mainly to the kind of
relationship between the two, with new clinical
responsibilities and certain organizational care delivery
features.” Presently, chronic illness is frustrating to
patients and care givers. Suggestions are given to
Ruiz-Párraga GT, López-Martínez AE, Gómez-Pérez L. 2012. Factor structure and psychometric properties of the resilience scale in a Spanish chronic musculoskeletal pain sample. J Pain. 13(11):1090-1098. "This article presents the first resilience questionnaire (RS-18) for chronic pain patients. The instrument obtained shows good reliability and validity. The results provide health-care professionals and researchers with a measure of resilience in chronic pain patients that excludes items related to functional disability."
Ruiz-Saez M, Fernandez-de-las-Penas C,
Blanco CR et al. 2007. Changes in pressure pain
sensitivity in latent myofascial trigger points in the upper
trapezius muscle after a cervical spine manipulation in
pain-free subjects. J Manipulative Physiol Ther.
30(8):578-583. “Our results suggest that a cervical spine
manipulation directed at the C3 through C4 segment induced
changes in pressure pain sensitivity in latent MTrPs in the
upper trapezius muscle. Different therapeutic mechanism,
either segmental or central, may be involved at the same time.”
Rulh A. 2005. Glial cells in the gut.
Neurogastroenterol Motil 17(6):777-790. [This
may have relevance to central sensitization in both FMS and
Howard B.V. 2002. Dyslipidemia of the metabolic
syndrome. Curr Cardio Rep 4(6):494-500.
“...these lipoprotein defects contribute largely to the
increased cardiovascular disease risk in individuals with
Ruscheweyh R, Sandkuhler J. 2005.
Opioids and central sensitization: II. Induction and
reversal of hyperalgesia. Eur J Pain 9(2):149-152.
“Opioids are powerful analgesics when used to treat acute
pain and some forms of chronic pain. In addition,
opioids can preempt some forms of central sensitization.”
This paper reviews evidence that opioids may also induce and
also perhaps reverse some forms of central sensitization.
Rush SM, Christensen JC, Johnson CH.
2000. Biomechanics of the first ray. Part II:
Metatarsus primus varus as a cause of hypermobility. A
three-dimensional kinematic analysis in a cadaver model.
J Foot Ankle Surg 39(2):68-77. [Tightness of
foot muscles, such as that due to myofascial TrPs, could be
a major and unrecognized cause of foot hypermobility. DJS]
Rusiecki, RS. 1998.
Chest pain as result of temporomandibular disorder (TMD). Gen
Russell AL, McCarty MF. 2000.
DL-phenylalanine markedly potentiates opiate analgesia – an
example of nutrient/pharmaceutical up-regulation of the
endogenous analgesia system. Med Hypotheses
Russell IJ. 2011. Future perspectives in generalized musculoskeletal pain syndromes. Best Pract Res Clin Rheumatol. 25(2):321-331. "This article describes contemporary controversies regarding two categories of soft-tissue pain (STP) - chronic widespread pain and fibromyalgia syndrome.... STP classification divides relevant painful conditions into three subgroups, depending on the extent of body involvement (localized, regional and generalized). Fibromyalgia syndrome, in the generalized STP category, is distinguished from other types of chronic widespread pain by virtue of its greater severity. During the past 20 years, the diagnosis of fibromyalgia was based on a research classification (1990 American College of Rheumatology Research Classification Criteria (1990 ACR RCC)) that requires a history of chronic widespread pain and the examination finding of widespread mechanical allodynia. A new approach (2010 American College of Rheumatology Fibromyalgia Diagnostic Criteria (2010 ACR FDC)), validated for clinical use, still requires a history of chronic widespread pain, but the examination is replaced by a historical assessment of co-morbid symptom severity. The populations identified by the two criteria are similar but not identical. Misuse of the new criteria could expand fibromyalgia from 2 to 10% of the general population. Avoidance of the term 'fibromyalgia' could return it to the obscurity from whence it came, leaving a much larger problem in its stead."
Russell IJ. 2004. Developments in
the fibromyalgia syndrome. J Musculoskeletal Pain
12(3/4):47-57. “The FMS is no longer unknown to the
medical practitioner. This new status requires
practical diagnostic criteria validated for use in community
care, a common nomenclature, a better understand of
pathogenesis, and effective treatment modalities.
Remarkably, there is dramatic progress in all of these
areas.” This excellent overview provides reasons for
identifying subgroups of FMS, some new and promising
medications, and the need for training and clarification on
2003. Dissecting the Mechanisms of Soft Tissue Pain. J
Muscoloskel Pain 11(2):1-2. In this editorial, Dr.
Russell stresses that he believes the importance of
identifying subgroups of FMS patients will become much more
important in deciding the most effective treatment options.
[I agree with this totally and urge clinicians to take under
consideration initiating factors and perpetuating factors when
developing FMS treatment regimens. DJS]
2003. Depression and soft tissue pain. J
Musculoskel Pain 11(1):1-3. “The old arguments
that depression is the cause of low back pain or of pain in
patients with fibromyalgia are clearly lame from multiple
unsupported parades, but it is fair to say that the resilience
of the human spirit becomes less elastic in the presence of
Russell, IJ. 1999.
Is fibromyalgia a distinct clinical entity? The clinical
investigator’s evidence. Baillieres Best Pract Res
Clin Rheumatol 13(3):445-54.
Russell, IJ. 1999.
Reliability of clinical assessment measures for the
classification of myofascial pain syndrome. J
Musculoskel Pain 7(1-2):309-324.
Russell, IJ. 1999.
The reliability of algometry in the assessment of patients
with fibromyalgia syndrome. J Musculoskel Pain
Russell, IJ. 1998.
Advances in fibromyalgia: possible role for central
neurochemicals. Am J Med Sci 315(6):377-384.
Russell IJ, Holman AJ, Swick TJ et al. 2011. Sodium oxybate reduces pain, fatigue and sleep disturbance and improves functionality in fibromyalgia: results from a 14-week, randomized, double-blind, placebo-controlled study. Pain. [Mar 10 Epub ahead of print]. "These results expand the evidence from previous clinical trials suggesting that SXB is effective and safe in FM. This study expands evidence from previous trials that sodium oxybate provides safe, effective treatment for multiple symptoms experienced by patients with fibromyalgia."
Russell IJ, Larson AA. 2009.
Neurophysiopathogenesis of fibromyalgia syndrome: a unified
hypothesis. Rheum Dis Clin North Am.
35(2):421-435. “The characteristic presenting
complaint of patients with fibromyalgia syndrome (FMS) is
chronic widespread allodynia. Research findings
support the view that FMS is an understandable and treatable
neuropathophysiologic disorder. The pain of FMS is
often accompanied by one or more other manifestations, such
as affective moods, cognitive insecurity, autonomic
dysfunction, or irritable bowel or bladder. Growing
evidence suggests that this is a familial disorder with many
underlying genetic associations. New findings from
brain imaging and polysomnography imply that FMS may be a
disorder of premature neurologic aging. A conceptual
model at the molecular level is proposed to explain many of
the observed features of FMS. The model can also
explain anticipated responses to FDA approved pharmacologic
therapies.” [It is unknown at this time as to how much
of the irritable bladder and bowel and autonomic dysfunction
and other symptoms often attributed to FM may in actuality
be due to co-existing TrPs. This model is very interesting,
and as genetic research and epigenetic research unfolds,
those of us with FM can look forward to more answers. DJS]
Russell IJ, Crofford LJ, Leon
T et al. 2009. The effects of pregabalin on sleep
disturbance symptoms among individuals with fibromyalgia
syndrome. Sleep Med. [Apr 30 Epub ahead of
print]. “These data demonstrate improvement in
FM-related sleep dysfunction with pregabalin therapy.
The majority of this benefit was a direct effect of
pregabalin on the patients’ insomnia, while the remainder
occurred through the drug’s analgesic activity.”
Russell IJ, Mease P, Smith T et al.
2007. The safety and efficacy of duloxetine for the
treatment of fibromyalgia syndrome in patients with or
without major depressive disorder: results from a 6-month
randomized, double-blind, placebo-controlled, fixed-dosed
trial. J Musculoskel Pain 15 (Supp 13):58 item
103. [Myopain 2007 Poster] “DLX60 (duloxetine 60 mg)
and DLX120 mg/d are efficacious and safe treatment options
for pain associated with FMS, whether or not MDD (major
depressive disorder) is present.”
Russell, IJ, JE
Michalek, YK Kang and AB Richards. 1999. Reduction of morning
stiffness and improvement in physical function in fibromyalgia
syndrome patients treated subligually with low doses of human
interferon-alpha. J Interferon Cytokine Res
Russell, IJ , GA
Vapriao, JE Michalek, FE Craig, YK Kang and AB Richards. 1999.
Lymphocyte markers and natural killer cell activity in
fibromyalgia syndrome: effects of low-dose, subligually use of
human interferon-alpha. J Interferon Cytokine Res
Russell, IJ, JE
Michalek, JD Fletchas, and GE Abraham. 1995. Treatment of
fibromyalgia syndrome with Super Malic; a randomized, double
blind, placebo controlled, crossover pilot study. J
Russo, C. M. and W. G.
Brose. 1998. Chronic pain. Annu Rev Med 49:123-33.
Ruster M, Franke S, Spath M et al.
2005. Detection of elevated
N(epsilon)-carboxymethyllysine levels in muscular tissue and
in serum of patients with fibromyalgia. Scand J
Rheumatol. 34(6):460-463. “Both mechanisms may
contribute to the development, perpetuation, and spreading
of pain characteristic in FM patients.”
Rustoen T, Wahl AK, Hanestad BR et al.
2005. Age and the experience of chronic pain:
differences in health and quality of life among younger,
middle-aged and older adults. Clin J Pain
21(6):513-523. “The prevalence rates for chronic pain
do vary with age and the middle-aged group may be a
high-risk group of patients with chronic pain.” [This
may indicate that chronic pain precursors such as individual
TrPs and developing initiators of FMS such as lack of
restorative sleep are not being diagnosed and adequately
treated. We may be seeing a lack of medical training
as a major perpetuating factor of chronic pain. DJS]
Rusy, L. M., S. A.
Harvey and D. J. Beste. 1999. Pediatric fibromyalgia and
dizziness: evaluation of vestibular function. J Dev Behav
Mouttapa M, Wood PB. 2009. Symptom clusters in
fibromyalgia: potential utility in patient assessment and
treatment evaluation. Nurs Res. 58(5):359-367.
“In this well-educated, primarily Caucasian sample, morning
stiffness, fatigue, and not feeling rested in the morning were
the symptoms with the highest severity scores.” “The
findings support the heterogeneity of the FM experience and the
presence of symptom clusters within the greater spectrum of
symptoms comprising the FM syndrome. These observations
suggest the possibility of tailoring interventions based upon
individual patient symptomatology.” [This article did not
consider the co-existing TrPs, so many of the symptoms ascribed
to FM may actually be due to TrPs. DJS]
Ryabow S. I.
2002. Extracellular space volume changes in the cerebral
cortex evoked by repetitive peripheral stimulation. Glia
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Ryan E, Malboeuf CM, Barnard M et al. 2006.
Cyclooxygenase-2 Inhibition attenuates antibody responses
against human papillomavirus-like particles. J Immunol
177:7811-7819. Some common over-the counter and other pain
medications might weaken vaccines. Vaccines are give to
produce a response of antibodies. Any COX inhibitor, such as
aspirin, Advil, Celebrex, etc., may attenuate this. In people
with compromised immune systems, the effect may be even more