Salinsky M, Storzbach D, Munoz S. 2010. Cognitive effects of pregabalin in healthy volunteers: A double-blind, placebo-controlled trial. Neurology. 74(9):755-61. Background: “Antiepileptic drugs (AEDs) can be associated with neurotoxic side effects including cognitive dysfunction, a problem of considerable importance given the usual long-term course of treatment. Pregabalin is a relatively new AED widely used for the treatment of seizures and some types of chronic pain including fibromyalgia. We measured the cognitive effects of 12 weeks of pregabalin in healthy volunteers.”  “At conventional doses and titration, pregabalin induced mild negative cognitive effects and neurotoxicity complaints in healthy volunteers. These effects are one factor to be considered in the selection and monitoring of chronic AED therapy. …This study provides Class I evidence that pregabalin 300 mg BID negatively impacts cognition on some tasks in healthy volunteers.” [This is important research. There seems to be a tendency for those in the field of complex chronic pain conditions, and for patients with these conditions,  to search for “magic wand” cures. We haven’t found one for FM yet. This medication causes neurotoxicity in healthy individuals. We already know that neurotoxins are produced by the body each time a TrP twitches, and that TrPs are common if not ubiquitous in FM patients. Some FM patients may produce quinolinic acid (instead of the healthy amount of needed serotonin) by means of the kynurenine pathway. One thing we don’t need is more neurotoxicity.  DJS]

Schmechel DE, Edwards C. 2012. Fibromyalgia, mood disorders, and intense creative energy: A1AT polymorphisms are not always silent. Neurotoxicology. [Mar 10 Epub ahead of print]. "Persons with single copies of common alpha-1-antitrypsin polymorphisms such as S and Z are often considered 'silent carriers'. Published evidence however supports a complex behavioral phenotype or trait - intense creative energy ("ICE") -associated with A1AT polymorphisms. We now confirm that phenotype and present an association of fibromyalgia syndrome (FMS) and A1AT in a consecutive series of neurological patients....Our findings support the ICE behavioral phenotype for A1AT polymorphism carriers and the reported association with anxiety and bipolar spectrum disorders. We now extend that phenotype to apparent vulnerability to inflammatory muscle disease in a spectrum from JRA to fibromyalgia (FMS) and specific behavioral subsets of ADD, PTSD, and specific late onset neurological syndromes (FTD-PD and PPA). High and low risk FMS subsets can be defined using A1AT, MTHFR and APOE genotyping. Clinical diagnoses associated with A1AT polymorphisms included fibromyalgia, JRA/JIA, bipolar disorder, PTSD, primary progressive aphasia and FTDPD, but not most Alzheimer Disease subtypes. These results support an extended phenotype for A1AT mutation carriers beyond liver and lung vulnerability to selective advantages: ICE phenotype and disadvantages: fibromyalgia, affective disorders, and selected late onset neurological syndromes."

Schmelz M. 2006.  [Interactions between itch and pain.]  Hautarzt [Apr 5 Epub ahead of print]  [German]  “Chronic inflammatory diseases can locally sensitize nerve endings and thereby contribute to itch.  ….there is increasing evidence that also central processing of itch can be sensitized in pruritus patients.  Interestingly, this pattern of peripheral and central sensitization in pruritus has striking similarities to the one observed in chronic pain patients.  The presumed similarities in underlying sensitizing mechanisms between itch and pain has major therapeutic consequences as successful therapies for chronic pain might be used also in chronic itch.”

Schmidt G, Alvarenga R , Manhaes A et al. 2017. Attentional performance may help to identify duloxetine responders in chronic pain fibromyalgia patients. Eur J Pain. [Epub ahead of print] "The data were interpreted considering that persistent pain in fibromyalgia is maintained by central sensitization that may be associated with functional changes in the dorsolateral prefrontal cortex and the posterior parietal cortex. In responsive patients, duloxetine treatment may be responsible for a partial recovery of these regions. This may explain the early attentional improvement observed in the responsive patients after 1 week of treatment. Thus, attentional performance may help to predict which patients will respond to duloxetine treatment even before they can demonstrate subjective improvements in pain perception."

Schneider E, Moore ES, Stanborough R, et al. Effects of trigger point dry needling on strength measurements and activation levels of the gluteus medius: A quasi-experimental randomized control study. Int J Sports Phys Ther. 2022 Dec 1;17(7):1404-1416. "Latent trigger points have been identified as a source of impaired muscle function giving rise to a reduction in force production and alterations in muscle activation patterns and movement efficiency…. Application of TDN (trigger point dry needling) to latent trigger points within the gluteus medius can significantly increase gluteus muscle force production immediately following intervention while reducing the level of muscle activation required during contraction."

Schneider, M. J. 1995. Tender Points/fibromyalgia vs. trigger points/myofascial pain syndrome: a need for clarity in terminology and differential diagnosis. J Manip. Physiol Ther 18(6):398-406.

Schneider R. 2017. Effectiveness of myofascial trigger point therapy in chronic back pain patients is considerably increased when combined with a new, integrated, low-frequency shock wave vibrotherapy (Cellconnect Impulse®): A two-armed, measurement repeated, randomized, controlled pragmatic trial. J Back Musculoskelet Rehabil. [Aug 4 Epub ahead of print] "Combining MT with the Cellconnect Impulse enhances the physiotherapeutic effectiveness of treating chronic back pain."

Schneider-Helmert D. 2003.  [Do we need polysomnography in insomnia?]  Schweiz Rundsch Med Prax. 92(48):2061-2066. [German]  “In the field of differential diagnosis, overlapping of insomnia with other disturbances within and outside the range of sleep medicine is frequent.  Special problems arise in chronic non-organic pain.  It is clear from all these aspects that PSG [polysomnography–sleep study] is indispensable in insomnia.”

Schneider-Helmert D, Whitehouse I, Kumar A et al. 2001.  Insomnia and alpha sleep in chronic non-organic pain as compared to primary insomnia. Neuropsychobiology 43(1):54-58.  This study indicates that insomnia in chronic pain patients may not be due to the pain itself.  It should not be dismissed as a given part of the chronic pain picture.  “It is suggested that insomnia in chronic pain patients should be taken seriously and treated by its specific methods.”

Schoenberger NE, Shif SC, Esty ML et al. 2001.  Flexyx neurotherapy system in the treatment of traumatic brain injury: an initial evaluation.  J Head Trauma Rehabil 16(3):260-274.  This type of brain wave modulation neurotherapy appears to be a promising therapy for traumatic brain injury.

Schonen J. 2004.  Tension-type headache and fibromyalgia: what’s common, what’s different?  Neurol Sci 25 (Suppl 3):S157-159.

Schoofs N, Bambini D, Ronning P et al. 2004.  Death of a lifestyle: the effects of social support and healthcare support on the quality of life of persons with fibromyalgia and/or chronic fatigue syndrome.  Orthop Nurs. 23(6):364-374.  “Social support, unlike healthcare support, is related to quality of life (QOL).  Subjects suffering from CFS and/or FMS do not experience high levels of social support.”

Schreiber KL, Belfer I, Miaskowski C et al. AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery. J Pain. 2019 Sep 4 [Epub ahead of print] "Acute pain after breast surgery decreases the quality of life of cancer survivors. …A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the five dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)- American Academy of Pain Medicine (AAPM)-American Pain Society (APS) Pain Taxonomy) to acute pain after breast surgery….The AAAPT provides a framework to define and guide improved assessment of acute pain after breast surgery, which will enhance generalizability of results across studies and facilitate meta-analyses and studies of inter-individual variation and underlying mechanism. It will allow researchers and clinicians to better compare between treatments, across institutions, and with other types of acute pain." [TrPs may be latent, to be activated later by cancer and /or surgery for same. Research indicates much chronic post-cancer pain may be preventable by treating related TrPs and other causes. DJS]

Schrepf A, Harper DE, Harte SE et al. 2016. Endogenous opioidergic dysregulation of pain in fibromyalgia: a PET and fMRI study. Pain. [May 30 Epub ahead of print.] "These findings are the first to link endogenous opioid system tone to regional pain-evoked brain activity in a clinical pain population. Our data suggests that dysregulation of the endogenous opioid system in fibromyalgia could lead to less excitation in antinociceptive brain regions by incoming noxious stimulation, resulting in the hyperalgesia and allodynia commonly observed in this population."

Schrepf A, Harte SE, Miller N et al. 2017. Improvement in the spatial distribution of pain, somatic symptoms, and depression following a weight-loss intervention. J Pain. [Aug 25 Epub ahead of print] "Weight loss may improve diffuse pain and comorbid symptoms commonly seen in chronic pain participants."

Schrepf A, Phan V, Clemens JQ et al. 2019. ICD-10 codes for the study of chronic overlapping pain conditions in administrative databases. J Pain. [May 30 Epub ahead of print] "Chronic Overlapping Pain Conditions (COPCs) are a set of painful chronic conditions characterized by high levels of co-occurrence. It has been hypothesized that COPCs co-occur in many cases because of common neurobiological vulnerabilities. In practice, most research on COPCs has focused upon a single index condition with little effort to assess comorbid painful conditions. This likely means that important phenotypic differences within a sample are obscured. The International Classification of Diseases (ICD) coding system contains many diagnostic classifications that may be applied to individual COPCs, but there is currently no agreed upon set of codes for identifying and studying each of the COPCs. Here we seek to address this issue through three related projects: a) we first compile a set of ICD-10 codes from expert panels for ten common COPCs, b) we then use natural language searches of medical records to validate the presence of COPCs in association with the proposed expert codes, c) finally, we apply the resulting codes to a large administrative medical database to derive estimates of overlap between the ten conditions as a demonstration project. The codes presented can facilitate administrative database research on COPCs….This article presents a set of ICD-10 codes that researchers can use to explore the presence and overlap of Chronic Overlapping Pain Conditions (COPCs) in administrative databases. This may serve as a tool for estimating samples for research, exploring comorbidities and treatments for individual COPCs, and identifying mechanisms associated with their overlap." [I have yet to find a patient with FM who does not have other illnesses. When the central nervous system is sensitized, something is sensitizing it. Doctors are taught differential diagnosis, and medicine is based on that model. Chronic pain patients often have interactive diagnoses. Thyroid resistance, insulin resistance, CRPS, FM, chronic myofascial pain and dysfunction, Ehlers-Danlos Syndrome--these conditions do not do well in a model of differential diagnosis. The codes we have are insurance codes for the benefit of insurance compensation, and yet they are called "diagnostic" codes. There are no insurance codes for myofascial trigger points, and yet there are codes for being hurt by an orca. It can be frustrating for clinicians to try to fit chronic pain diagnostic reality into insurance codes. DJS]

Schrier M, Amital D, Arnson Y et al. 2011. Association of fibromyalgia characteristics in patients with non-metastatic breast cancer and the protective role of resilience. Rheumatol Int. [Sep 8 Epub ahead of print]. "Women with breast cancer tend to develop chronic widespread pain syndromes more often than do healthy women."

Schroeder B, Sanfilippo JS, Hertweck SP. 2000.  Musculoskeletal pelvic pain in a pediatric and adolescent gynecology practice.  J Pediatr Adolesc Gynecol. 13(2):90. “MS (musculoskeletal) etiologies of pelvic pain are common in the adolescent age group and respond well to physical therapy.  Physical therapy might be employed as an early intervention prior to surgery in adolescent girls with unexplained pelvic pain.”  Research indicates that these patients are NOT good candidates for surgery as often the pain is myofascial in origin, and surgery is seldom needed if the cause of the pain can be found.

Schubert MS. 2004.  Allergic fungal sinusitis. Otolaryngol Cli North Am. 37(2):301-326.  

Schuh-Hofer S, Wodarski R, Pfau DB et al. 2013. One night of total sleep deprivation promotes a state of generalized hyperalgesia: a surrogate pain model to study the relationship of insomnia and pain. Pain. 154(9):1613-1621. "Our findings show that a single night of TSD is able to induce generalized hyperalgesia and to increase State Anxiety scores. In the future, TSD may serve as a translational pain model to elucidate the pathomechanisms underlying the hyperalgesic effect of sleep disturbances."

Schuler M, Njoo N, Hestermann M et al. 2004. Acute and chronic pain in geriatrics: clinical characteristics of pain and the influence of cognition.  Pain Med. 5(3):253-262.

Shultz SP, Driban JB, Swanik CB. 2007. The evaluation of electrodermal properties in the identification of myofascial trigger points. Arch Phys Med Rehabil 88(6):780-784. The area of a TrP, either active or latent, has significant increased skin electrical resistance that decreases as with the distance from the TrP.

Schuster AK, Wettstein M, Gerhardt A et al. 2018. Eye pain and dry eye in patients with fibromyalgia. Pain Med. [Mar 15 Epub ahead of print] "Eye pain and dry eye are common in chronic pain patients, with comparable prevalence in musculoskeletal pain patients with and without fibromyalgia."

Schwagerus L, K Dörner K, Bender S et al. 2020. [Myofascial chronic pelvic pain in women: A retrospective evaluation of the effects of specific diagnostics and therapy] Schmerz. Jul 28. Online ahead of print. [Article in German] "Therapy components included manual therapeutic treatment, training in self-stretching exercises, medication with the active ingredients flupirtine or methocarbamol, as well as relaxation procedures….. A multimodal therapy concept with a manual therapeutic treatment focus can lead to an improvement in pain symptoms and quality of life in patients with myofascial chronic pelvic pain after a treatment period of 120 days. Myofascial syndromes of urogenital muscles must be considered in the assessment of the cause of chronic pelvic pain." [Pelvic care providers need to be trained in diagnosing and treating myofascial trigger points. DJS]

Schwaller F, Fitzgerald M. 2014. The consequences of pain in early life: injury-induced plasticity in developing pain pathways. Eur J Neurosci. 39(3):344-352. "Pain in infancy influences pain reactivity in later life, but how and why this occurs is poorly understood. Here we review the evidence for developmental plasticity of nociceptive pathways in animal models and discuss the peripheral and central mechanisms that underlie this plasticity. Adults who have experienced neonatal injury display increased pain and injury-induced hyperalgesia in the affected region but mild injury can also induce widespread baseline hyposensitivity across the rest of the body surface, suggesting the involvement of several underlying mechanisms, depending upon the type of early life experience. Peripheral nerve sprouting and dorsal horn central sensitization, disinhibition and neuroimmune priming are discussed in relation to the increased pain and hyperalgesia, while altered descending pain control systems driven, in part, by changes in the stress/HPA axis are discussed in relation to the widespread hypoalgesia. Finally, it is proposed that the endocannabinoid system deserves further attention in the search for mechanisms underlying injury-induced changes in pain processing in infants and children."

Schwarm FP, Stein M, Uhl E et al.Spinal cord stimulation for the treatment of complex regional pain syndrome leads to improvement of quality of life, reduction of pain and psychological distress: a retrospective case series with 24 months follow up. Scand J Pain. 2019 Nov 19. [Epub ahead of print] " Complex regional pain syndrome (CRPS) is a common pain condition which is characterized by pain, functional impairment, and trophic changes. Neurosurgical treatment is not widely offered.... The results of this small case series showed a significant improvement of the EQ-5D-5L after implantation of a neurostimulator. NRS reduction was not significant but a clear tendency towards reduced values was observed. We therefore conclude that SCS is an alternative option to relieve chronic pain and psychological distress originating from CRPS if non-invasive managements of severe CRPS failed.... SCS is an alternative option to improve the quality of life and relieve chronic pain originating from severe CRPS if conservative treatment modalities fail."

Schwartz M.J., Offenbacher M., Neumeister A. et al. 2002. Evidence for an altered tryptophan metabolism in fibromyalgia. Neurobiol Dis 11(3):434-442.  This study shows an altered tryptophan metabolism in a subgroup of fibromyalgia patients.

Schwartz MJ, Offenbaecher M, Neumeister A et al.  2003.  Experimental evaluation of an altered tryptophan metabolism in fibromyalgia.  Adv Exp Med Biol. 527:265-275.  “These data demonstrate an altered TRP metabolism in a subgroup of FM patients, where the TD seems to activate 5-HT metabolism and IL-6 production.”

Schwartz N, Temkin P, Jurado S et al. 2014. Chronic pain: Decreased motivation during chronic pain requires long-term depression in the nucleus accumbens. Science 345(6296):535-542. This study was undertaken to find if reduces motivation in chronic pain states in mice are due to dysfunction sin neural circuits. These researchers found that a dysfunction in neural circuitry was required in chronic pain states before depression of specific excitatory synaptic transmissions reduced motivation to initiate or complete goal-directed tasks. This neural defect dampens the pleasure response areas. The researchers believe that this isn't the only reason for reduced motivation in chronic pain states, but it does validate the feelings of chronic pain patients.

Schwartz RG, Gall NG, Grant AE. 1984.  Abdominal pain in quadriparesis: myofascial syndrome as unsuspected cause.  Arch Phys Med Rehabil. 65(1):44-46.  “This is a case report of a 47-year-old man with C6 quadriparesis who presented with tenderness in the right lower quandrant of his abdomen which was diagnosed as iliocostalis myofascial syndrome.  Diagnosis of nephrolithiasis and appendicitis were considered, but the complete blood count, abdominal x-ray, intravenous pyelogram, and sonogram were all normal.  His symptoms became progressively more severe over the ensuing 2-week period.  Examination at that time revealed extreme tenderness to light touch in the right lower quandrant, right flank, and right posterior subcostal area.  A trigger point in the right iliocostalis muscle referred pain to the right lower quandrant.  In the absence of evidence of internal derangement a diagnosis of iliocostalis myofascial syndrome was made.  A 3-day course of ‘spray and stretch’ to the iliocostalis cleared the symptoms.  This case illustrates that myofascial syndrome should be considered in the differential diagnosis of soft tissue pain in the patient with spinal cord injury and sensory sparing.”

Scolnik M, Vasta B, Hart DJ et al. 2016. Symptoms of Raynaud's phenomenon (RP) in fibromyalgia syndrome are similar to those reported in primary RP despite differences in objective assessment of digital microvascular function and morphology. Rheumatol Int. [May 2 Epub ahead of print.] This study found no direct relationship between color changes in the skin and temperature of the digits in FM patients with Raynaud's following a local cold challenge, unlike primary Raynaud's, but otherwise no difference in symptoms.

Scott JR, Hassett AL, Brummett CM et al. 2017. Caffeine as an opioid analgesic adjuvant in fibromyalgia. J Pain Res. 28;10:1801-1809. "Caffeine consumption was associated with decreased pain and symptom severity in opioid users, but not in opioid nonusers, indicating caffeine may act as an opioid adjuvant in fibromyalgia-like chronic pain patients. These data suggest that caffeine consumption concomitant with opioid analgesics could provide therapeutic benefits not seen with opioids or caffeine alone." Free Article

Scott JR, Hassett AL, Schrepf AD et al. 2018. Moderate alcohol consumption is associated with reduced pain and fibromyalgia symptoms in chronic pain patients. Pain Med. [Mar 13 Epub ahead of print] "Moderate alcohol consumption in chronic pain patients was associated with decreased pain severity and interference, fewer painful body areas, lower somatic and mood symptoms, and increased physical function. A similar effect was observed in non-FM patients, but to a lesser extent in FM patients, suggesting chronic pain patients with less centralized forms of pain may benefit most from moderate alcohol consumption." [In FM, by definition there is widespread diffuse pain. Localized pain in FM pat is due to co-existing conditions such as myofascial TrPs. It is mystifying that the authors note "fewer painful body areas". Subjects were not assessed for co-existing conditions causing localized pain. DJS]

Scott KM, Fisher LW, Bernstein IH et al. 2016. The treatment of chronic coccydynia and post-coccygectomy pain with pelvic floor physical therapy. PM R. [Aug 23 Epub ahead of print.] This is from the pelvic floor rehab clinic at the Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX. "The primary treatment intervention was pelvic floor physical therapy aimed at pelvic floor muscle relaxation. Secondary treatment interventions included the prescription of baclofen for muscle relaxation (19% of patients), ganglion impar blocks (8%), or coccygeus trigger point injections (17%)…. Mean average pain ratings in post-coccygectomy patients improved from 6.64 to 3.27. Higher initial pain scores and a history of prior injections were correlated with higher pain scores upon completion of physical therapy. Pain duration and history of trauma did not affect treatment outcomes. CONCLUSIONS: Pelvic floor physical therapy is a safe and effective method of treating coccydynia".

Scott NA, Guo B, Barton PM et al. 2009.  Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review.  Pain Med. 10(1):54-69.  “TPI (trigger point injection) is a safe procedure when used by clinicians with appropriate expertise and training.  It relieved symptoms when used as a sole treatment for patients with chronic head, neck, shoulder, and back pain or whiplash syndrome, regardless of the injectant used, and may be a useful adjunct to intra-articular injection in the treatment of osteoarthritis pain.  Although the addition of TPI to stretching exercises augments treatment outcomes, this was also true of other therapies such as ultrasound and laser.”  “The only advantage of injecting anesthetic into trigger points may be to reduce the pain of the needling process, which may not be an insignificant benefit.”

Seas, K. L. and H. W. Clark. 1993. Opioid use in the treatment of chronic pain: assessment of addiction. J Pain Symptom Manage 8(5):257-264.

Sedighi A, Nakhostin Ansari N, Naghdi S. 2017. Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. J Bodyw Mov Ther. 21(4):810-814. "The purpose of this study (from Iran) was to compare the acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache….The application of dry needling into trigger points of suboccipital and upper trapezius muscles induces significant improvement of headache index, trigger points tenderness, functional rating index and range of motion in patients with cervicogenic headache. Deep dry needling had greater effects on CROM and function."

Seegal, R. F., J. R. Wolpaw and R. Dowman. 1989. Chronic exposure of primates to 60-Hz electric and magnetic fields: II. Neurochemical effects. Bioelectromagnetics 10(3):289-301.

Seematter G, Binnert C, Martin JL et al. 2004.  Relationship between stress, inflammation and metabolism.  Curr Opinion Clin Nutr Metab Care 7(2):169-173.  The HPA axis stress response mobilizes neuroendocrine response systems that can institute a metabolic cascade with far-reaching consequences.  “They also exert anti-insulin actions and may in the long-term induce a state of insulin resistance.  In addition, stress stimulates inflammatory mediators in mononuclear cells.  Given the possible role of low-grade inflammation in chronic metabolic disorders, this suggests that stress may be a factor in the development of insulin resistance and the metabolic syndrome.”   Stress and causes of same, including pain, must be controlled.

Segura-Jimenez V, Carbonell-Baeza A, Aparicio VA et al. 2012. A Warm Water Pool-Based Exercise Program Decreases Immediate Pain in Female Fibromyalgia Patients: Uncontrolled Clinical Trial. Int J Sports Med. [Dec 20 Epub ahead of print]. Fibromyalgia is characterized by chronic and extended musculoskeletal pain. The combination of exercise therapy with the warm water may be an appropriate treatment. However, studies focusing on the analysis of immediate pain during and after an exercise session are rare. This study aimed to determine the immediate changes of a warm water pool-based exercise program (12 weeks) on pain (before vs. after session) in female fibromyalgia patients. 33 Spanish women with fibromyalgia were selected to participate in a 12 week (2 sessions/week) low-moderate intensity warm water pool-based program. We assessed pain by means of a Visual Analogue Scale before and after each single session….a warm water pool-based exercise program for 12 weeks (2 times/week) led to a positive immediate decrease in level of pain in female patients with fibromyalgia. Improvements were higher in older women and in those with more intense pain.

Segura-Jimenez V, Estevez-Lopez F, Soriano-Maldonado A et al. 2016. Gender differences in symptoms, health-related quality of life, sleep quality, mental health, cognitive performance, pain-cognition, and positive health in Spanish fibromyalgia individuals: The Al-Ándalus Project. Pain Res Manag. 2016:5135176. "The results of the present study do not support consistent evidence of gender differences in fibromyalgia-related symptoms. However, it seems that detriment of some symptoms (especially pain) in fibromyalgia men compared with their nonfibromyalgia counterparts is greater than those of fibromyalgia women compared with their nonfibromyalgia peers." Free PMC Article

Segura-Jimenez V, Romero-Zurita, Carbonell-Baeza A et al. 2013. Effectiveness of Tai-Chi for Decreasing Acute Pain in Fibromyalgia Patients. Int J Sports Med. [Nov 7 Epub ahead of print]. "Tai-Chi has shown benefits in physical and psychological outcomes in diverse populations. We aimed to determine the changes elicited by a Tai-Chi program (12 and 24 weeks) in acute pain (before vs. after session) in fibromyalgia patients. We also assessed the cumulative changes in pain brought about by a Tai-Chi program….In conclusion, a low-moderate intensity Tai-Chi program for 12 weeks (3 times/week) decreased levels of acute pain in fibromyalgia patients. A longer period is necessary (e. g. 24 weeks) for observing cumulative changes in pain."

Segura-Jimenez V, Soriano-Maldonado A, Alvarez-Gallardo IC et al. 2015. Subgroups of fibromyalgia patients using the 1990 American College of Rheumatology criteria and the modified 2010 preliminary diagnostic criteria: the al-Andalus project. Clin Exp Rheumatol. Aug 5. [Epub ahead of print] "Our results reinforce the understanding of fibromyalgia as a heterogeneous condition. Subgrouping of fibromyalgia patients is highly recommendable, since these subgroups show diverse clinical pictures and therefore treatment options should be individually tailored to their specific profile."

Seidel MF, Weinreich GF, Stratz T et al. 2007.  5-HT3 receptor antagonists regulate autonomic cardiac dysfunction in primary fibromyalgia syndrome.  Rheumatol Int. [Jul 19 Epub ahead of print].  “Tropisetron reduced not only pain perception but also had a favorable effect on cardiac dysfunction during treatment.”  [This medication seems to be effective for both FM and myofascial pain, as well as cardiac dysfunction. DJS]

Sendur OF, Gurer G, Bozbas GT. 2006.  The frequency of hypermobility and its relationship with clinical findings of fibromyalgia patients.  Clin Rheumatol. [Apr 25 Epub ahead of print]  “...more severe clinical findings were observed in FM patients with hypermobility when compared with ones without.”

Şengül M, Tekeli Şengül S. 2024. Efficacy of trigger point injection therapy in noncardiac chest pain: A randomized controlled trial. Turk J Phys Med Rehabil. 2024 Feb 1;70(1):98-104. "This study aimed to compare the effects of trigger point injections (in the pectoralis muscle) and stretching exercises in patients with noncardiac chest pain (NCCP) associated with myofascial pain syndrome…. Conclusion: Trigger point injection combined with stretching exercises is an efficient treatment for noncardiac chest pain related to myofascial pain syndrome compared to exercise treatment alone.

Senior BA, Khan M, Schwimmer C et al. 2001.  Gastroesophageal reflux and obstructive sleep apnea.  Laryngoscope 111(112):2144-6.  “These results suggest a potential relationship between OSA and GER...”  Treatment of one may significantly impact the other in some patients.

Şenol D, Ucar C, Toy S, et al. 2021. Analysis of the effects of hypothalamic-pituitary-adrenal axis activity in menstrual cycle on ankle proprioception, dynamic balance scores and visual-auditory reaction times in healthy young women. J Musculoskelet Neuronal Interact. Mar 1;21(1):85-92. "It was found that neuromuscular performance and postural control was negatively affected by HPA axis activity in M (mensturation) phase of MC (menstrual cycle) and by pain, which is a significant menstrual symptom." [This could highlight a perpetuating factor for FM and TrPs. DJS]

Seo HG, Bang MS, Chung SG et al. 2012. Effect of electrical stimulation on botulinum toxin A therapy in patients with chronic myofascial pain syndrome: A 16-week randomized double-blinded study. Arch Phys Med Rehabil. [Oct 31 Epub ahead of print]. Short-term electrical stimulation may affect reduction in pain after BTX-A injection at TrPs in patients with chronic MPS on the neck and shoulder regions. Based on the results, it seems that sensory electrical stimulation was superior to motor electrical stimulation as an adjuvant therapy of BTX-A injection in the patients with chronic MPS. Further studies are warranted to investigate the method facilitating the effect of BTX-A on MPS.

Seo S, Jung YH, Lee D, et al. 2021. Abnormal neuroinflammation in fibromyalgia and CRPS using [11C]-(R)-PK11195 PET. PLoS One. Feb 8;16(2):e0246152. "The results suggested that abnormal neuroinflammation can be an important pathological factor in FM. In addition, the identification of common and different critical regions related to abnormal neuroinflammation in FM, compared with patients with CRPS and healthy controls, may contribute to improved diagnosis and the development of effective medical treatment for patients with FM."

Seok J, Warren HS, Cuenca AG et al. 2013. Genomic responses in mouse models poorly mimic human inflammatory diseases. Proc Natl Acad Sci USA. [Feb 11 Epub ahead of print]. This study shows that the commonly used mouse as an experimental model does not translate well to human applications in the context of inflammatory disease. How a mouse responds in an experiment does not indicate how a human will respond. [One very small step for mouse-kind. DJS]

Sephton SE, Salmon P, Weissbecker I et al. 2007.  Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: results of a randomized clinical trial.  Arthritis Rheum. 57(1):77-85.  “This meditation-based intervention alleviated depressive symptoms among patients with fibromyalgia.”

Sepici V, Tosun A, Kokturk O. 2007.  Obstructive sleep apnea syndrome as an uncommon cause of fibromyalgia: a case report.  Rheumatol Int. [Jun 23 Epub ahead of print].

Sergey A, Dzugan R, Arnold Smith R. 2002.  Hypercholesterolemia treatment: a new hypothesis or just an accident?  Med Hypoth 59(6):751-756.  This team’s “...findings support the hypothesis that hypercholesterolemia is a compensatory mechanism for life-cycle related down-regulation of steroid hormones and that broadband steroid hormone restoration is associated with a substantial drop in serum TC in many patients.”  This may be very important in treating FMS patients who often have many hormonal axes imbalanced.  It is vital that the hormone levels be tests and the normal amounts restored using natural hormones.

Sergi, M., M. Rizzi, A. Braghiroli, P. S. Puttini, M. Greco, M. Cazzola and A. Andreoli. 1999.  Periodic breathing during sleep in patients affected by fibromyalgia syndrome.  Eur Respir J 14(1):203-8.

Sergienko S, Kalichman L. 2015. Myofascial origin of shoulder pain: A literature review. J Bodyw Mov Ther. 19(1):91-101. "MTrPs (myofascial trigger points) in shoulder muscles is a common condition among patients with shoulder complaints and can be reliably diagnosed by palpation. The reviewed interventions seem to be effective in reducing pain, increasing range of motion and improving function of the painful shoulder."

Serpas DG, TMorton T, Zettel-Watson L, et al. The role of pain intensity and depressive symptoms in the relationship between sleep quality and postural control among middle-aged and older adults with fibromyalgia. Psychol Health. 2022 Sep 22;1-16. "Findings highlight the serial association of pain intensity and depressive symptoms with objective postural control performance and the potential for sleep and depression interventions that may maximize functional outcomes in FM and PPT in chronic unilateral shoulder pain."

Serra E, Spaeth M, Carbonell J et al. 2010. Development of the Fibromyalgia Burden Assessment: measuring the multifaceted burden of fibromyalgia. Clin Exp Rheumatol. 28(6 Suppl 63):S87-93. "The FMBA is a self-reported questionnaire allowing the assessment and a better understanding of the impacts of fibromyalgia and the burden associated with these on patients' daily lives. It is available in UK English, French, German and Spanish. Its scoring and validation remain to be undertaken."

Serra J, Collado A, Sola R et al. 2013. Hyperexcitable C nociceptors in fibromyalgia. Ann Neurol. [Nov 16 Epub ahead of print]. "Microneurography was used to record from C nociceptors of 30 female patients meeting criteria for fibromyalgia and compared with recordings from 17 female patients with small fiber neuropathy and 9 female controls…. The mechano-sensitive nociceptors in the fibromyalgia patients behaved normally, but the silent nociceptors in 76.6% of fibromyalgia patients exhibited abnormalities. Spontaneous activity was detected in 31% of silent nociceptors in fibromyalgia, 34% in small fiber neuropathy, and 2.2% in controls. Sensitization to mechanical stimulation was found in 24.2% of silent nociceptors in fibromyalgia, 22.7% in small fiber neuropathy, and 3.7% in controls. Abnormally high slowing of conduction velocity when first stimulated at 0.25 Hz was more common in fibromyalgia. Interpretation: We show for the first time that the majority of fibromyalgia patients have abnormal C nociceptors. Many silent nociceptors exhibit hyperexcitability resembling that in small fiber neuropathy, but high activity-dependent slowing of conduction velocity is more common in fibromyalgia patients, and may constitute a distinguishing feature. We infer that abnormal peripheral C nociceptor ongoing activity and increased mechanical sensitivity could contribute to the pain and tenderness suffered by patients with fibromyalgia."

Serrano-Ibanez ER, Rosa Esteve R, Ramírez-Maestre C et al. 2020. Chronic pain in the time of COVID-19: Stress aftermath and central sensitization. Br J Health Psychol. Oct 25. Online ahead of print. "Due to the COVID-19 situation, individuals with central sensitization pain syndromes may be at higher risk of developing psychological distress."

Seton B, Pandey R, Piscura MK, et al. Autonomic recalibration: A promising approach for alleviating myofascial pain explored in a retrospective case series. 2024. Cureus. 2024 Jan 17;16(1):e52450. Three diverse case reports are presented to illustrate the effectiveness of AR in patients with different sources of pain…. In all cases, AR resulted in pain relief, improved sleep, and restoration of functional abilities.

Shadmehr A, Jafarian Z, Tavakol K et al. 2013. Effect of pelvic compression on the stability of pelvis and relief of sacroiliac joint pain in women: A case series. J Musculoskel Pain. 21(1):31-36. "Pelvic compression significantly reduced the EMG (electromyographic) activity from six muscles....pelvic compression can improve both the motor control and stability of the pelvis, while reducing joint pain in women suffering from sacroiliac symptoms."

Shaffer SM, Brismee JM, Sizer PS et al. 2014. Temporomandibular disorders. Part 2: conservative management. J Man Manip Ther. 22(1):13-23. "Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described in part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables."

Shah AS, Raghuram A, Kaur K, et al. 2021. Specialty-specific diagnoses in pediatric patients with postconcussion syndrome: Experience from a multidisciplinary concussion clinic. Clin J Sport Med. 2021 Feb 16. Online ahead of print. "A wide variety of treatable, specialty-specific diagnoses were identified as potential contributing factors to patients' postconcussion symptoms. The most common treatable diagnoses included binocular vision dysfunction (76%), anxiety, (57.7%), depression (44.2%), new or change in refractive error (21.7%), myofascial pain syndrome (19.2%), and benign paroxysmal positional vertigo (17.5%).... Patients seen in a MDCC setting receive a high number of treatable diagnoses that are potentially related to patients' PCS symptoms."

Shah J. 2007.  Uncovering the biochemical milieu of myofascial trigger points using in-vivo microdialysis.  J Musculoskel Pain 15 (Supp 13):2 item 2.  [Myopain 2007 Poster]  The use of in-vivo sampling by microdialysis acupuncture needle “...provides us the unprecedented ability to safely explore and measure the local biochemical milieu of TrPs before, during and after a local twitch response.”  “...the local biochemical milieu does appear to change after a LTR.”  “...the vicinity of the active TrP exhibits a unique biochemical milieu of substances associated with pain and inflammation .... analyte abnormalities may not be limited to local areas of active TrPs.”

Shah JP, Danoff JV, Desai MJ et al. 2008.  Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points.  Arch Phys Med Rehabil. 89(1):16-23.  “We have shown the feasibility of continuous, in vivo recovery of small molecules from soft tissue without harmful effects.  Subjects with active MTPs in the trapezius muscle have a biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different from subjects with latent or absent MTPs in their trapezius.  These concentrations also differ quantitatively from a remote, uninvolved site in the gastrocnemius muscle.  The milieu of the gastrocnemius in subjects with active MTPs in the trapezius differs from subjects without active MTPs.”

Shah JP, Parikh S, Danoff J et al. 2007.  Re: the myofascial trigger point region: correlation between the degree of irritability and the prevalence of endplate noise.  Am J Phys Med Rehabil. 86(12 :1033-1034.

Shah JP, Phillips TM, Danoff JV et al. 2005.  An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle.  J Appl Physiol. 99(5):1977-1984.  This article describes a ground-breaking technique for measuring minute amounts of biochemicals in the body.  In this case, the biochemicals released in the interstitial fluid surrounding myofascial TrPs during TrP twitch were analyzed.  They found a sensitized and sensitizing soup of over 30 biochemicals released.  In the active TrP patient group, bradykinins, calcitonin gene-related peptide, IL-$, serotonin, tumor necrosis factor-", and norepinephrine were significantly higher and the pH dropped significantly than in the control group or the group with latent TrPs.  Substance P and CGRP dropped significantly after the TrP twitch release.  This study may indicate some of the cause of TrP pain, and also highlight promising targets for TrP pain relief.  [It also indicates some ways active TrPs can aggravate the central sensitization of fibromyalgia. DJS]

Shah JP, Thaker N, Heimur J et al. 2015. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM R. [Feb 24 Epub ahead of print.] "The intent of this paper is to discuss the evolving role of the myofascial trigger point (MTrP) in myofascial pain syndrome (MPS) from both a historical and scientific perspective. MTrPs are hard, discrete, palpable nodules in a taut band of skeletal muscle that may be spontaneously painful (i.e. active), or painful only on compression (i.e. latent). MPS is a term used to describe a pain condition which can be acute or, more commonly, chronic and involves the muscle and its surrounding connective tissue (e.g. fascia). According to Travell and Simons, MTrPs are central to the syndrome-but are they necessary? Although the clinical study of muscle pain and MTrPs has proliferated over the past two centuries, the scientific literature often seems disjointed and confusing. Unfortunately, much of the terminology, theories, concepts, and diagnostic criteria are inconsistent, incomplete, or controversial. In order to address these deficiencies, investigators have recently applied clinical, imaging (of skeletal muscle and brain), and biochemical analyses to systematically and objectively study the MTrP and its role in MPS. Data suggest that the soft tissue milieu around the MTrP, neurogenic inflammation, sensitization, and limbic system dysfunction may all play a role in the initiation, amplification, and perpetuation of MPS. The authors will chronicle the advances that have led to the current understanding of MTrP pathophysiology and its relationship to MPS, and review the contributions of clinicians and researchers who have influenced and expanded our contemporary level of clinical knowledge and practice."

Shah MA, Feinberg S, Krishnan E. 2006.  Sleep-disordered breathing among women with fibromyalgia syndrome.  J Clin Rheumatol. 12(6):277-281.  “A large proportion of women with fibromyalgia in a general rheumatology practice had sleep-disordered breathing, which can be detected using sleep polysomnograms.”

Shaheen NJ, Madanick RD, Alattar M et al. 2007.  Gastroesophageal Reflux Disease as an etiology of sleep disturbance in subjects with insomnia and minimal reflux symptoms: a pilot study of prevalence and response to therapy.  Dig Dis Sci. [Nov 6 Epub ahead of print].  “Despite the lack of GERD symptoms, a significant minority of subjects with sleep disturbance have abnormal acid exposures.  These preliminary data suggest that aggressive treatment of GERD in such patients may result in improvement in sleep efficiency.”  [Care providers should first attempt to normalize the gut flora with the use of healthy diet, probiotics, prebiotics, supplements and non-invasive care such as frequency specific stimulation. DJS]

Shahimoridi D, Shafiei SA, Yousefian B. 2020. The effectiveness of the polarized low-level laser in the treatment of patients with myofascial trigger points in the trapezius muscles. J Lasers Med Sci. Winter;11(1):14-19. "This study assessed the effect of polarized low-level laser therapy (PLLLT) on the treatment of myofascial trigger points (MTrPs) in the trapezius muscles. Its effectiveness in pain reduction was compared to low-level laser therapy (LLLT). … Conclusion: PLLLT and LLLT can effectively treat MTrPs in the trapezius muscles and they reduce RP, LNM, PMTB, and SMTB in particular. However, the effect of the LLLT was significantly greater than that of PLLLT."

Shamshery C, Kumar VV, Agarwal A, et al. 2021. Comparative evaluation of efficacy of fluoroscopy and ultrasound for iliopsoas block: A randomised trial Turk J Anaesthesiol Reanim. Aug;49(4):284-291. "FL and US both are effective modalities for IP muscle injection as they provide equal relief from pain, disability and psychological stress. US guided IP injections are easier to learn and perform in comparison with FL."

Shanahan, F. 1999.  Brain-gut axis and mucosal immunity: a perspective on mucosalpsychoneuroimmunology.  Semin Gastrointest Dis 10(1):8-13.

Shankar H, Cummings C. 2012. Ultrasound Imaging of Embedded Shrapnel Facilitates Diagnosis and Management of Myofascial Pain Syndrome. Pain Pract [Oct 24 Epub ahead of print]. "Trigger points can result from a variety of inciting events including muscle overuse, trauma, mechanical overload, and psychological stress....A veteran was referred to the pain clinic for management of his severe headache following a gunshot wound to the neck with shrapnel embedded in the neck muscles a few years prior to presentation. He had no other comorbid conditions. Physical examination revealed a taut band in the neck. An ultrasound imaging of the neck over the taut band revealed the deformed shrapnel located within the levator scapulae muscle along with an associated trigger point in the same muscle. Ultrasound guided trigger point injection, followed by physical therapy resolved his symptoms."

Shankar H, Reddy S. 2012. Two- and Three-Dimensional Ultrasound Imaging to Facilitate Detection and Targeting of Taut Bands in Myofascial Pain Syndrome. Pain Med. [Jun 8 Epub ahead of print]. This is a case report using ultrasound elastography. Conservative TrP therapy had been insufficient to resolve pain and reduced range of motion of the shoulder. "Three-dimensional ultrasound images provided evidence of aberrancy in the architecture of the muscle fascicles around the taut bands compared to the adjacent normal muscle tissue during serial sectioning of the accrued image. On two-dimensional ultrasound imaging over the palpated taut band, areas of hyperechogenicity were visualized in the trapezius and supraspinatus muscles. Subsequently, the patient received ultrasound-guided real-time lidocaine injections to the trigger points with successful resolution of symptoms....This is a successful demonstration of utility of ultrasound imaging of taut bands in the management of myofascial pain syndrome. Utility of this imaging modality in myofascial pain syndrome requires further clinical validation." [This method is a research method and not presently accessible for clinical applications. DJS]

Shanmugam S, Mathias L, Manickaraj N, et al. 2021. Intramuscular electrical stimulation combined with therapeutic exercises in patients with shoulder adhesive capsulitis: A randomised controlled trial. Int J Surg Protoc. May 18;25(1):71-83."Myofascial trigger points (MTrPs) precipitate the shoulder pain severity and disability in patients with shoulder adhesive capsulitis (SAC). This study aims to compare the effectiveness of intramuscular electrical stimulation (IMES) combined with therapeutic exercises versus dry needling (DN) combined with therapeutic exercises in improving the clinical outcomes in patients with SAC….IMES combined with therapeutic exercises is an effective treatment to reduce the shoulder pain severity and upper limb disability by deactivating the active and latent MTrPs and improving the shoulder abduction and external rotation range of motion in patients with SAC."

Shanmugam S, Mathias L, Thakur A et al. 2016. Effects of Intramuscular electrical stimulation using inversely placed electrodes on myofascial pain syndrome in the shoulder: A case series. Korean J Pain. 29(2):136-140. "Myofascial pain syndrome (MPS) is one of the common musculoskeletal conditions of the shoulder which may develop sensory-motor and autonomic dysfunctions at the various level of the neuromuscular system. The pain and dysfunction caused by MPS were primarily treated with physical therapy and pharmacological agents in order to achieve pain free movements. However, in recent years intramuscular electrical stimulation (IMES) with conventional electrode placement was used by researchers to maximize therapeutic values. But, in this study an inverse electrode placement was used to deliver electrical impulses intramuscularly to achieve neuro-modulation at the various level of the nervous system. Nine patients with MPS were treated with intramuscular electrode stimulation using inversely placed electrodes for a period of three weeks. All nine subjects recovered from their shoulder pain and disability within the few weeks of intervention. So, this inverse electrode placement may be more appropriate for chronic pain management." Free PMC Article [It is good to see an article that takes as a given that autonomic symptoms can be caused by trigger points. Many doctors don't know this. DJS]

Shannon, C. N. and A. P. Baranowski. 1997. Use of opioids in non-cancer pain. Br J Hosp Med58(9):459-463.

Shanoudy H, Soliman A, Moe S, Hadian D et al. 2001. manifestations of Asick euthyroid@ syndrome in patients with compensated chronic heart failure. J Card Fail 7(2):146-52. "Patients with compensated CHF display the derangements in thyroid hormone metabolism of impaired peripheral conversion of T(4) and t(3) and increased production of rT(3) in the presence of normal dynamic function of the hypothalamic-pituitary-thyroid axis, which are consistent with early manifestations of a sick euthyroid state."

Sharan D. 2014. Myofascial pain syndrome: Diagnosis and Management. Indian J Rheum. 9(S22-S25). This review of myofascial pain due to trigger points clearly emphasizes the need to diagnose and treat the condition as soon as possible. Early care can prevent so much misery. This condition is often missed or misdiagnosed, and the patients pay for this lack of awareness. Further central sensitization can and must be prevented by prompt diagnosis of acute trigger points, saving resources and preventing much needless pain.

Sharan D, Ajeesh PS, Rameshkumar R et al. 2012. Risk factors, clinical features, and outcome of treatment of work related musculoskeletal disorders in on-site clinics among IT companies in India. Work. Suppl 1:5702-5704. This study focused on the IT (information technology) profession and workplace risk in India. It found poor office ergonomics; lack of keyboard and/or mouse tray and foot rest; and improper monitor height to be the most common risk factors. The most common musculoskeletal disorders were myofascial pain syndrome (49.2%), thoracic outlet syndrome (25%), and fibromyalgia (8.5%). The body regions affected mostly were neck (64.9%), shoulder 42.1%), lower back (56.5%), and thigh (34.2%). The patients were treated with the RECOUP protocol designed by Dr. Sharan, and the patients were satisfied with their progress.

Sharan D, Jacob BN, Ajeesh PS et al. 2011. The effect of cetylated fatty esters and physical therapy on myofascial pain syndrome of the neck. J Bodyw Mov Ther. 15(3):363-374. Myofascial pain patients were treated with either a combination of cetylated fatty ester complex (CFEC) and 1.5% menthol or a control cream of 1.5% menthol. The patients treated with the compound containing the CFEC experienced significantly improved symptoms compared with those who used the menthol cream. [Patients on guaifenesin should be aware that the cream available in the USA, Celadrin, has significant peppermint oil and would be contraindicated due to the salicylates in it. DJS]

Sharan D, Manjula M, Urmi D et al. 2014. Effect of yoga on the Myofascial Pain Syndrome of neck. Int J Yoga. 7(1):54-59. "Myofascial Pain Syndrome (MPS) refers to pain attributed to muscle and its surrounding fascia, which is associated with "myofascial trigger points" (MTrPs). MTrPs in the trapezius has been proposed as the main cause of temporal and cervicogenic headache and neck pain. Literature shows that the prevalence of various musculoskeletal disorders (MSD) among physiotherapists is high. Yoga has traditionally been used to treat MSDs in various populations. But there is scarcity of literature which explains the effects of yoga on reducing MPS of the neck in terms of various physical parameters and subjective responses. Therefore, a pilot study was done among eight physiotherapists with minimum six months of experience. A structured yoga protocol was designed and implemented for five days in a week for four weeks. The outcome variables were Disability of Arm, Shoulder and Hands (DASH) score, Neck Disability Index (NDI), Visual Analogue Scale (VAS), Pressure Pain Threshold (PPT) for Trigger Points, Cervical Range of Motion (CROM) - active & passive, grip and pinch strengths. The variables were compared before and after the intervention. Finally, the result revealed that all the variables ….improved significantly after intervention."

Sharan D, Mohandoss M, Ranganathan R et al. 2014. Musculoskeletal disorders of the upper extremities due to excessive usage of hand held devices. Ann Occ Env Med. 26:22. This retrospective study from India was held on 70 subjects with upper extremity MSD from handheld devices. "All of the subjects reported pain in the thumb and forearm with associated burning, numbness and tingling around the thenar aspect of the hand, and stiffness of wrist and hand. 43 subjects had symptoms on the right side; 9 on the left and 18n had bilateral symptoms.…All the subjects were diagnosed to have tendinosis of the extensor pollicis longus and myofascial pain syndrome affecting the 1st interossei, thenar group of muscles and extensor digitorum communis….All subjects recovered completely following the rehabilitation."

Sharan D, Rajkumar JS, Mohandoss M. 2014. Myofascial low back pain treatment. Curr Pain Headache Rep.18(9):449. "Myofascial pain is a common musculoskeletal problem, with the low back being one of the commonest affected regions. Several treatments have been used for myofascial low back pain through physical therapies, pharmacologic agents, injections, and other such therapies. This review will provide an update based on recently published literature in the field of myofascial low back pain along with a brief description of a sequenced, multidisciplinary treatment protocol called Skilled Hands-on Approach for the Release of myofascia, Articular, Neural and Soft tissue mobilization (SHARANS) protocol. A comprehensive multidisciplinary approach is recommended for the successful management of individuals with myofascial low back pain."

Sharma V. 2016. Tramadol-induced hypomania and Serotonin Syndrome. Prim Care Companion CNS Disord. 18(6). Free Article

Shear, D. A., J. Dong, K. L. Haik-Creguer, T. J. Bazzett, R. L. Albin and G. L. Dunbar. 1998.Chronic administration of quinolinic acid in the rat striatum causes spatial learning deficits in a radial arm water maze task. Exp Neurol 150(2):305-311.

Sheikhhoseini R, Arab AM. 2018. Dry Needling in myofascial tracks in Non-Relaxing Pelvic Floor Dysfunction: A case study. J Bodyw Mov Ther. Apr;22(2):337-340. "The aim of this case report is to describe the use of Dry Needling (DN) in myofascial tracks related to the pelvic floor (PF) in the management of a male with Non-Relaxing Pelvic Floor Dysfunction (NRPFD).... A 42-year-old man, with a 20-year history of frequent urination, was referred to the physical therapy clinic by a urologist with diagnosis of NRPFD. The patient was suffering from a sense of incomplete evacuation and difficulty to start urination. He had to urinate every 30 min. The initiation of urination was so difficult that patient had to facilitate it by splashing warm water on his penis.... DN was performed for 10 sessions. The first three sessions were performed every other day in the same week. In the second week, DN was performed twice at three-day intervals, and the other sessions were performed such that one session was held per week. Selected stretching exercises were prescribed in the first session. The results showed that the patient had reported no urination during sleep, and urination six to eight times when was awake. A three-month follow-up with a telephone-based interview showed that the symptoms did not recur."

Sherry DD, Brake L, Tress JL et al. 2015. The treatment of juvenile fibromyalgia with an intensive physical and psychosocial program. J Pediatr. [Jul 21 Epub ahead of print.] "Children with fibromyalgia can be successfully treated without medications with a very intensive PT/OT and psychotherapy program. They have significantly improved pain and function by subject report and objective measures of function." Free Article [Every child with fibromyalgia is different, and co-existing conditions can significantly alter this conclusion. DJS]

Sherwin, B. B. 1998. Estrogen and cognitive functioning in women. Proc Soc Exp Biol Med217(1):17-22.

Sheth T, Pitchumoni CS, Das KM. 2014. Musculoskeletal manifestations in inflammatory bowel disease: A revisit in search of immunopathophysiological mechanisms. J Clin Gastroenterol. [Jan 31 Epub ahead of print.] "Inflammatory bowel diseases are chronic inflammatory disorders of multiple organ systems, primarily involving the gut, with chronic relapsing and remitting course. Musculoskeletal involvement is the most common extraintestinal manifestation. Distinct cell-mediated and humoral immunopathophysiological mechanisms have been identified underlying gut and joint inflammation in patients with inflammatory bowel disease and arthritis. Genetic polymorphisms in genes coding for NOD2 and IL12/IL23 complex lead to impaired antigenic handling in the gut and local immune dysregulation. The gut-synovial axis hypothesis implicates both environmental and host factors acting as triggers to initiate inflammation in genetically predisposed individuals, leading to priming of Th1 and Th17 lymphocytes in the gut and subsequent homing to the synovial tissue. Similar to gut, antibody-dependent cell-mediated cytotoxicity and complement-mediated cell lysis may also contribute to the joint damage. Involvement of peripheral joints occurs in 2 distinct manners, one being oligoarticular asymmetric arthritis associated with active disease and the other being polyarticular symmetric involvement of small joints. The axial involvement may include asymptomatic sacroiliitis, inflammatory back pain, and ankylosing spondylitis, running an independent clinical course. Noninflammatory involvement of the musculoskeletal system may present as osteopenia, osteonecrosis, fibromyalgia, or myopathies, leading to significant impact on quality of life."

Shi H, Yuan C, Dai Z et al. 2016. Gray matter abnormalities associated with fibromyalgia: A meta-analysis of voxel-based morphometric studies. Semin Arthritis Rheum. 46(3):330-337. "The current meta-analysis identified a characteristic pattern of GM (gray matter) alterations within the medial pain system, default mode network, and cerebro-cerebellar circuits, which further supports the concept that fibromyalgia is a symptom complex involving brain areas beyond those implicated in chronic pain." [Fibromyalgia is more than just chronic pain. Yet some doctors still think it is psychological. We need to educate. DJS]

Shigetoh H, Abiko T, Ohyama M, et al. Associations of central sensitization-related symptoms with low back pain-related factors and work status in caregivers. Int J Environ Res Public Health. 2022 Aug 16;19(16):10135. "Low back pain (LBP) is associated with psychological factors and central sensitization-related symptoms (CSSs).… Caregivers with more severe CSSs tended to exhibit worse LBP intensity…, widespread pain, catastrophic thinking, and pain self-efficacy…, and they also tended to experience work interference…. Caregivers without CSSs tended to receive a smaller amount of assistance with a lower frequency… The number of participants with an adequate environment and equipment was significantly less in the moderate/severe CSS group…. Thus, our findings may suggest that CSS severity is associated with LBP intensity, widespread pain, psychological factors, and work status in caregivers."

Shigetoh H, Tanaka Y, Koga M, et al. 2019. The mediating effect of central sensitization on the relation between pain intensity and psychological factors: A cross-sectional study with mediation analysis. Pain Res Manag. Apr 8;2019:3916135. "Central sensitization (CS) and psychological factors are associated with pain intensity; however, the mediating role of CS on the relation between psychological factors and pain intensity remains unclear.... The relationship among anxiety symptoms, depression symptoms, and pain intensity was completely mediated by CS. Furthermore, the relationship between catastrophic thinking and pain intensity was partially mediated by CS. Our findings suggest that CS mediates relation between psychological factors and pain intensity, and CS-focused intervention may be important." [This article indicates that the co-existing psychological factors result from the CS, rather than the reverse. DJS]

Shilo, L., Y. Dagan, Y. Smorjik, U. Weinberg, S. Dolev, B. Komptel, H. Balaum and L. Shenkman. 1999. Patients in the intensive care unit suffer from severe lack of sleep associated with loss of normal melatonin secretion pattern. Am J Med Sci 317(5):278-81.

Shin HJ, Shin JC, Kim WS et al. 2014. Application of ultrasound-guided trigger point injection for myofascial trigger points in the subscapularis and pectoralis muscles to post-mastectomy patients: a pilot study. Yonsei Med J. 55(3):792-799. "In post-mastectomy patients with shoulder pain, US-guided trigger point injections of the subscapularis and/or pectoralis muscles are effective for both diagnosis and treatment when the cause of shoulder pain is suspected to originate from active MTrPs in these muscles, particularly, the subscapularis."

Shiravi S, Letafatkar A, Bertozzi L et al. 2019. Efficacy of Abdominal Control Feedback and Scapula Stabilization Exercises in Participants With Forward Head, Round Shoulder Postures and Neck Movement Impairment. Sports Health. Apr 23:1941738119835223. "The addition of abdominal control feedback to the scapular stabilization exercises was shown to be superior to the scapular stabilization exercises alone for decreasing neck pain and restoring proper proprioception, strength, and electromyography in females with forward head and round shoulder postures and neck movement impairment."

Shirvalkar P, Prosky J, Chin G, et al. First-in-human prediction of chronic pain state using intracranial neural biomarkers. Nat Neurosci. 2023 Jun;26(6):1090-1099. "Chronic pain syndromes are often refractory to treatment and cause substantial suffering and disability. Pain severity is often measured through subjective report, while objective biomarkers that may guide diagnosis and treatment are lacking. Also, which brain activity underlies chronic pain on clinically relevant timescales, or how this relates to acute pain, remains unclear. Here four individuals with refractory neuropathic pain were implanted with chronic intracranial electrodes in the anterior cingulate cortex and orbitofrontal cortex (OFC). Participants reported pain metrics coincident with ambulatory, direct neural recordings obtained multiple times daily over months. We successfully predicted intra-individual chronic pain severity scores from neural activity with high sensitivity using machine learning methods. Chronic pain decoding relied on sustained power changes from the OFC, which tended to differ from transient patterns of activity associated with acute, evoked pain states during a task. Thus, intracranial OFC signals can be used to predict spontaneous, chronic pain state in patients." [Imagine having an objective measure of pain! DJS]

Shmushkevich Y, Kalichman L. 2013. Myofascial pain in lateral epicondylalgia: A review. J Bodyw Mov Ther. 17(4):434-439. "There is an ongoing debate about the myofascial component, characterized by the presence of myofascial trigger points (MTrPs) in lateral epicondylalgia (LE)…." The objectives of this study were: "To review current evidence of the association between myofascial pain and LE, including efficacy of treatment, focusing on myofascial pain….PubMed, Google Scholar and PEDro databases were searched without search limitations from inception until October 2012 for terms relating to LE and MTrPs….Two observational studies showed a high prevalence of MTrPs in LE patients compared to healthy controls. Three randomized controlled trials demonstrated significant improvement in pain and functional outcomes after application of soft tissue techniques, focusing on the myofascial component. Myofascial pain and MTrPs may be part of the LE etiology. Treatment focusing on the myofascial component seems to be effective in reducing pain and improving function in patients with LE. Additional trials are essential to attain a solid conclusion." [Since some studies still use the term "myofascial pain" to mean TMJD, and so very many researchers are not even aware of myofascial trigger points or lack the training and experience needed to palpate them, previous research is only as good as the training. There should be no "ongoing debate" about the myofascial component of LE. There are only those experienced and well-trained in the techniques of palpating TrPs and those who are not. Disagreements between those who are trained and those who are not, does not constitute a true debate. To have a controversy, there must be science on both sides. Researchers who do not understand the ubiquity of TrPs are churning out incomplete and often flawed research. Quantity does not equal quality. The "debate" will continue until they all become enlightened. Until then, bad research will beget more bad research. This study is not bad, but reflects the need for education. DJS]

Shmygalev S, Dagtekin O, Gerbershagen HJ et al. 2014. Assessing cognitive and psychomotor performance in patients with fibromyalgia syndrome. Pain Ther. Oct 25. [Epub ahead of print] "The results of the present study demonstrate that, in general, the driving ability of patients with FMS was not inferior to that of healthy volunteers based on a standardized computer-based test battery. However, variables, such as younger age, depression, anxiety, fatigue, pain, and poor motor coordination, likely contribute to the subjective perception of cognitive dysfunction in FMS."

Shomal Zadeh F, Koh RGL, Dilek B, et al. Identification of myofascial trigger point using the combination of texture analysis in B-Mode ultrasound with machine learning classifiers. Sensors (Basel). 2023 Dec 16;23(24):9873. New methods of imaging TrPs are being developed.

Shoskes DA, Berger R, Elmi A et al. 2007.  Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study.  J Urol. [Dec 12 Epub ahead of print].  "Myofascial pain is a possible etiology for category III chronic prostatitis/chronic pelvic pain syndrome, either secondary to infection/inflammation or as the primary cause."  "Abdominal/pelvic tenderness is present in half of the patients with chronic pelvic pain syndrome…."

Shresher NM, Mohamed AE, Elshahaly MH. 2019. Performance of 2016 revised fibromyalgia diagnostic criteria in patients with rheumatoid arthritis. Rheumatol Int. [Aug 3 Epub ahead of print] "FM coexists in a substantial number of RA patients according to the 2016 revised criteria and associated with high composite disease activity measures. Therefore, assessment of FM should be considered in RA patients with persistently high disease activity."

Shrivastava K, Naidu G, Gupta M et al. 2016. Fibrofascitis - An enigma for the dentist: A case report. J Clin Diagn Res. 10(4):ZD04-5. "Fibromyalgia is a chronic syndrome that causes widespread musculoskeletal pain and stiffness throughout the connective tissues that support and move the bones and joints. Pain and localized tender points occur in the muscles, particularly those that support the neck, spine, shoulders, and hips. Moreover the disorder includes fatigue, depression, sleep disturbances and constipation. A combination of treatments including medications, patient education, physical therapy and counseling are usually recommended. Here, we present a case report of fibromyalgia and the treatment given to the patient, a combination of dental and orthopedic treatment." Free PMC Article [This patient is fortunate, as this lead author dentist and colleagues in India have extensive understanding of both fibromyalgia and chronic myofascial pain and dysfunction. The article is well worth reading. DJS]

Siddiq MA, Khasru MR, Rasker JJ. 2014. Piriformis syndrome in fibromyalgia: clinical diagnosis and successful treatment Case Rep Rheumatol. 2014;2014:893836. Epub Sep 22."Piriformis syndrome is an underdiagnosed extraspinal association of sciatica. Patients usually complain of deep seated gluteal pain. In severe cases the clinical features of piriformis syndrome are primarily due to spasm of the piriformis muscle and irritation of the underlying sciatic nerve but this mysterious clinical scenario is also described in lumbar spinal canal stenosis, leg length discrepancy, piriformis myofascial pain syndrome, following vaginal delivery, and anomalous piriformis muscle or sciatic nerve. In this paper, we describe piriformis and fibromyalgia syndrome in a 30-year-old young lady, an often missed diagnosis."

Siddiq MAB, Clegg D, Al Hasan A et al. 2020. Extra-spinal sciatica and sciatica mimics: a scoping review. Korean J Pain. Oct 1;33(4):305-317. "While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are: piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome, cluneal nerve disorder, and osteitis condensans ilii. In some cases, extra-spinal sciatica may have a catastrophic course when the sciatic nerve is involved in cyclical sciatica, or the piriformis muscle in piriformis pyomyositis. In addition to cases of sciatica with clear spinal or extra-spinal origin, some cases can be a product of both origins; the same could be true for pseudo-sciatica or sciatica mimics, we simply don't know how prevalent extra-spinal sciatica is among total sciatica cases."[Note that some cases of piriformis syndrome, "walletosis", and cluneal nerve disorder can be caused by MTrPs. DJS]

Sido B, Dumoulin FL, Homann J et al. 2013. [Surgical interventions in patients with mast cell activation disease: Aspects relevant for surgery using the example of a cholecystectomy.] Chirurg. [Dec 15 Epub ahead of print.] [Article in German] "Systemic mast cell activation disease (MCAD) is characterized by an increased and unregulated release of mast cell mediators which can evoke a multifaceted clinical picture often resembling irritable bowel syndrome or fibromyalgia. Because of the considerable prevalence (~ 17 %) of MCAD surgeons are frequently unwittingly confronted with MCAD patients in whom unexpected intraoperative and postoperative complications may occur. Therefore, knowledge of the particular requirements is of relevance for surgical treatment of MCAD patients….Due to the high prevalence of MCAD in the general population it can be assumed that the frequency in the surgical patient population is similar. If a patient has MCAD, specific characteristics should be taken into account in the surgical procedure to avoid increased operative and complication risks resulting from MCAD."

Siegmeth, W. 1999. [No title available]. Wien Med Wochenschr 149(19-20):558-60 [German].

Sigmundsson H. 2005.  Disorders of motor development (clumsy child syndrome).  J Neural Transm Suppl. (69):51-68.  “Research has shown that about 6-10% of children have motor competences well below the norm.  It is unusual for motor problems to simply disappear over time.  In the absence of intervention the syndrome is likely to manifest itself.”  “...clumsiness must be seen as a neurological insufficiency.”

Sikandar S, Aasvang EK, Dickenson AH. 2016. Scratching the surface: the processing of pain from deep tissues. Pain Manag. 6(2):95-102. "Although most pain research focuses on skin, muscles, joints and viscerae (organs) are major sources of pain. We discuss the mechanisms of deep pains arising from somatic and visceral structures and how this can lead to widespread manifestations and chronification. We include how both altered peripheral and central sensory neurotransmission lead to deep pain states and comment on key areas such as top-down modulation where little is known. It is vital that the clinical characterization of deep pain in patients is improved to allow for back translation to preclinical models so that the missing links can be ascertained. The contribution of deeper somatic and visceral tissues to various chronic pain syndromes is common but there is much we need to know."

Sikdar S, Ortiz R, Gebreab T et al. 2010. Understanding the vascular environment of myofascial trigger points using ultrasonic imaging and computational modeling. Conf Proc IEEE Eng Med Biol Soc. 1:5302-5305. "Recently, our research group has developed new ultrasound imaging methods to visualize and characterize MTrPs and their surrounding soft tissue. The goal of this paper was to quantitatively analyze Doppler velocity waveforms in blood vessels in the neighborhood of MTrPs to characterize their vascular environment.... 16 patients with acute neck pain were recruited for the study and the blood vessels in the upper trapezius muscle in the neighborhood of palpable MTrPs were imaged using Doppler ultrasound. Preliminary findings show that symptomatic MTrPs have significantly higher peak systolic velocities and negative diastolic velocities compared to latent MTrPs and normal muscle sites. Using compartment modeling, we show that a constricted vascular bed and an enlarged vascular volume could explain the observed flow waveforms with retrograde diastolic flow."

Sikdar S, Shah JP, Gebreab T et al. 2009. Novel Applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehab. 90(11):1829-1838. Nine subjects meeting Travel land Simons criteria for trigger points were assessed with physical evaluation, pressure algometry, and 3 types of ultrasound including grayscale 2D US, vibration sonoelastography and Doppler. The imaging techniques were capable of distinguishing myofascial trigger points from surrounding tissue. Tau bands were not investigated; only the contraction nodules. The studies support Simons' Integrated Hypothesis of Trigger Point Formation, indicating areas of hypoxic energy crisis and/or tissue damage at the contraction nodules. Although the operator was blinded as to the location of the nodules, the imaging made it obvious, as they were easily differentiated from the surrounding tissue. The authors warn that "…this study is exploratory and descriptive, and the findings are from a small number of subjects." They are also exceedingly expensive research studies and dependent on one operator, and in no way can be construed as clinically available. With the use of all of these types of techniques, it is possible to image myofascial trigger points. It may be some time in the future before any clinical use can be made of this, but the authors are working on standardizing the technique. [After this study from the National Institutes of Health–and others, there is absolutely no way that anyone can logically deny the existence of myofascial trigger points. The evidence was always there right under (trained, experienced) fingers. DJS]

Sil S, Lynch-Jordan A, Ting TV et al. 2012. The influence of family environment on long-term psychosocial functioning of adolescents with juvenile fibromyalgia. Arthritis Care Res (Hoboken). [Dec 19 Epub ahead of print]. "Results indicated that family environment during early adolescence significantly predicted greater depressive symptoms in early adulthood for both the JFM group and healthy controls. In particular, a controlling family environment (use of rules to control the family and allowing little independence) during early adolescence was the driving factor in predicting poorer long-term emotional functioning for patients with JFM. Family environment did not significantly predict longer-term physical impairment for either group."

Siler AC, Gardner H, Yanit K et al. 2010. Systematic Review of the Comparative Effectiveness of Antiepileptic Drugs for Fibromyalgia. J Pain. [Dec 9 Epub ahead of print]. "Fibromyalgia is a difficult-to-treat chronic pain syndrome that affects 2% of the US population. Pregabalin is an antiepileptic recently FDA approved for fibromyalgia treatment. Other antiepileptics have been suggested for treatment. This systematic review examines the relative benefits and harms of antiepileptic drugs in the treatment of fibromyalgia. A literature search was conducted and 8 studies matched criteria (7 studies of pregabalin, 1 of gabapentin). Both drugs reduced mean pain scores more than placebo at a modest rate (pregabalin, 38% to 50%; gabapentin, 51%). In a 6-month trial of pregabalin responders, 32% continued to have response at 6 months, with a mean time to loss of response of 34 days. Compared to placebo, the drugs had similarly high rates of adverse events and withdrawals. Without a head-to-head trial it is not possible to conclude if 1 antiepileptic is more effective or harmful than the other, although limited evidence suggests potential differences. Future studies must directly compare the drugs, include a more broadly defined population, examine long term benefits and harms, and include cointerventions. We conclude that pregabalin and gabapentin are modestly effective for the treatment of fibromyalgia but that their long-term safety and efficacy remain unknown….This systematic review evaluates the benefits and harms of using the antiepileptic drugs gabapentin and pregabalin for the treatment of fibromyalgia. Conclusions from this paper can help clinicians to more effectively treat the pain associated with fibromyalgia."

Silva KM, Tucano SJ, Kumpel C et al. 2012. Effect of hydrotherapy on quality of life, functional capacity and sleep quality in patients with fibromyalgia. Rev Bras Reumatol. 52(6):851-857. [English, Portuguese]. "Hydrotherapy improves sleep quality, physical function, professional status, psychological disorders and physical symptoms in patients with fibromyalgia."

Silva MP, Barrett JM, Williams JD. 2004.  A retrospective review of outcomes of fibromyalgia patients following physical therapy treatments.  J Musculoskel Pain 12(2):83-92.  Upledger’s cranio-sacral release therapy may be effective to decrease pain levels and medication and increase quality of life for FMS patients.

Silver DS, Wallace DJ. 2002. The management of fibromyalgia-associated syndromes.  Rheum Dis Clin North Am 28(2):405-17. "Most of the six million Americans with fibromyalgia have at least one associated syndrome which mandates specialized attention in addition to traditional therapeutic approaches.  The successful treatment of fibromyalgia-associated syndromes improves the symptoms, quality of life, and prognosis of fibromyalgia."

Simms, R. W. 1998. Fibromyalgia is not a muscle disorder. Am J Med Sci 315(6):346-350.

Simms, R. W. , C. A. Zerbini, N. Ferrante, J. Anthony, D. T. Felson and D. E. Craven. 1992. Fibromyalgia syndrome in patients infected with human immunodeficiency virus. the Boston City Hospital Clinical AIDS Team. Am J Med 92(4):368-374.

Simons DG. 1995.  Myofascial pain syndrome: One term but two concepts; a new understanding.  J Musculoskeletal Pain 3(1):7-14.  This paper is of vital importance.  It explains how some researchers have been using the term “myofascial pain syndrome (MPS)” as synonymous with temporomandibular dysfunction (TMJD), without explaining the definition.  [This practice is common in papers written by dentists.  This dangerous practice can lead to misleading or erroneous conclusions.  Others build on these conclusions, not realizing that authors are using the term MPS to mean TMJD, and may assume that they refer to myofascial pain due to trigger points that may occur in all four quadrants of the body.  Authors must be careful to define their terms. DJS] 

Simons DG, Mense S.  Diagnosis and therapy of myofascial trigger points.  Schmertz 17(6):419-424.  This verifies by muscle biopsy the segmental shortening of sarcomere groupings in individual muscle fibers, suggesting the mechanism behind myofascial trigger point taut band formation. It presents an integrated hypothesis for the pathophysiology of myofascial trigger points, beginning with the release of excess acetylcholine from dysfunctional motor endplates. [German]

Simons D. G. 2001.  Do endplate noise and spikes arise from normal motor endplates?  Am J. Phys Med Rehabil 80(2):134-40.  Endplate noise may be a commonly misunderstood phenomenon and needs to be more carefully assessed in regards to association with myofascial trigger points.

Simons, DG. 1999. Diagnostic criteria of myofascial pain caused by trigger points. J Musculoskel Pain 7(1-2):111-120.

Simons, D. G. 1993. Examining for myofascial trigger points. Arch Phys Med Rehabil 74:676.

Simons, D. G. and W. C. Stolov. 1976. Microscopic features and transient contraction of palpable bands in canine muscles. Am J Phys Med 55:65-88.

Simpson KH. 2002.  Individual choice of opioids and formulations: strategies to achieve the optimum for the patient.  Clin Rheumatol 21 Suppl 1:S5-S8.  “Recent years have seen a gradual shift towards the use of opioid therapy in chronic non-malignant pain (CNMP) following recognition that at least a subpopulation of such patients appears to benefit from long-term opioid treatment.  Misconceptions about opioids and the associated risk of dependence stemmed from older research that was fundamentally flawed.  Opioid treatment must therefore be individualized for each patient, based on a clear understanding of drug absorption, metabolism, toxic and binding characteristics, using opioid switching strategies where appropriate.  Practical guidelines for opioid therapy in MNMP include regular and systematic checks of treatment results to adjust therapy or each individual patient and to ensure optimum benefit.”

Simunovic, Z., T. Trobonjaca and Z. Trobonjaca. 1998. Treatment of medial and lateral epicondylitis–tennis and golfer’s elbow–with low level laser therapy: a multicenter double-blind, placebo-controlled clinical study on 324 patients. J Clin Laser Med Surg 16(3):145-51.

Simunovic, Z. 1996. Low level laser therapy with trigger points technique: a clinical study on 243 patients. J Clin Laser Med Surg 14(4):163-167.

Singh G, Abdul Hamid A.2021. Invalidation in fibromyalgia and rheumatoid arthritis and its effect on quality of life in Indian patients. Int J Rheum Dis. Jun 20. Online ahead of print. "Fibromyalgia (FM) and rheumatoid arthritis (RA) patients face invalidation in the form of "discounting" and "lack of understanding"…. Results: Fifty-five FM and 102 RA patients were included in the study. Compared to RA, FM patients had significantly higher discounting by spouse, family and medical professionals…. FM patients suffered more lack of understanding from spouse and medical professionals as compared to RA patients…. In RA patients discounting by spouse had weak to moderate negative correlation with psychological, social and environmental domains of WHOQoL…. FM patients faced more invalidation as compared to RA patients. Invalidation from spouse leads to poor QoL in RA and FM patients."

Singh, G., D. R. Ramey, D. Morfeld, H. Shi, H. T. Hatoum and J. F. Fries. 1996. Gastrointestinal tract complications of nonsteroidal anti-inflammatory drug treatment in rheumatoid arthritis. A prospective observational cohort study. Arch Intern Med 156(14):1530-1536.

Singh NJ, Khanna M, Gupta A, et al. Effectiveness of peripheral median, radial, and ulnar nerve block at wrist along with intra-articular steroid injection in shoulder joint in management of complex regional pain syndrome of upper limb: 1-week follow-up study. Neurol India. 2022 May-Jun;70(3):1064-1068." Complex regional pain syndrome (CRPS) of upper limbs is one of the under-recognized painful disabling condition seen in many neurological conditions…. Peripheral median, radial, and ulnar nerve block at wrist along with intra-articular steroid injection in the shoulder joint is an effective method of management of CRPS of the upper limb."

Singh R, Rai NK, Pathak A, et al. 2024. Impact of fibromyalgia severity on patients mood, sleep quality, and quality of life. J Neurosci Rural Pract. 2024 Apr-Jun;15(2):320-326. "With the increasing severity of fibromyalgia, not only does the pain increase but mood and sleep quality also deteriorate, which further impacts the QOL of FMS patients. Thus, comorbid mood derangements must also be screened and addressed for maximum benefit of the patients.

Singh R, Rai NK, Rastogi A, et al. 2021. Impact of sleep disturbances and autonomic dysfunction on the quality of life of patients with fibromyalgia. J Basic Clin Physiol Pharmacol. Feb 8. Online ahead of print. "Mild to moderate grade fibromyalgia patients have significant sleep disturbance, poor sleep quality which remarkably impacts their quality of life.... The study suggests that full spectrum of sleep disturbances and sleep quality should be explored in fibromyalgia syndrome (FMS) patients.

Singh RB, Kartik C, Otsuka K et al. 2002.  Brain-heart connection and the risk of heart attack. Biomed Pharmacother. 56 Suppl 2:257s-265s.  This article connects recent research linking conditions such as diabetes, ambient pollution, insulin resistance and mental stress with heart attack risk, gives some perpetuating factors of chest pain, and lists some possible protective mechanisms.

Sinz, E. H., P. M. Kochanek, M. P. Heyes, S. R. Wisniewski, M. J. Bell, R. S. Clark, S. T. DeKosky, A. R. Blight and D. W. Marion. 1998. Quinolinic acid is increased in CSF and associated with mortality after traumatic brain injury in humans. J Cereb Blood Flow Metab18(6):610-615.

Sirh SJ, Sirh SW, Mun HY et al. Importance of quadratus lumborum muscle trigger point injection and prolotherapy technique for lower back and buttock pain. Front Pain Res (Lausanne). 2022 Nov 22;3:997645. "Myofascial pain and enthesopathy of the quadratus lumborum muscle are important causes of lower back and/or buttock pain…. Herein, we describe for the first time a landmark-based integrated injection technique for the treatment of trigger points and myofascial pain in the quadratus lumborum; this technique is safe, effective, and can be used with or without steroids, fluoroscopy, or ultrasound guidance."

Sirianni J, Ibrahim M, Patwardhan A. 2015. Chronic pain syndromes, mechanisms, and current treatments. Prog Mol Biol Transl Sci. 131:565-611. Although acute pain is a physiological response warning the human body of possible harm, chronic pain can be a pathological state associated with various diseases or a disease in itself. In the United States alone, around one-third of the population has experienced a chronic pain condition and annual cost to the society is in the range of 500-600 billion dollars. It should be noted that if at all this is a very modest estimate; it surpasses the costs associated with cancer, heart disease, and diabetes combined. Unfortunately, despite these humongous costs, the treatment of chronic pain is inadequate. Chronic pain affects individuals in a variety of forms, and below we highlight some of the most common chronic pain conditions seen in a pain clinic. Most of these disorders are difficult to treat and typically require multimodal therapy including pharmacotherapy, behavioral modification, and targeted interventions. We have summarized the scope of each disorder, clinical features, proposed mechanisms, and current therapies for them…

Sirikaku K, Watinaga GK, de Souza Moraes S, et al. Effect of dry needling on the masseter muscle in the tinnitus perception of patients with temporomandibular disorder. J Maxillofac Oral Surg. 2023 Sep;22(3):571-578. "Dry needling combined with counseling was associated with improvement in pain intensity and tinnitus, decrease in tinnitus discomfort and reduction in total THI (Tinnitus Handicap Inventory) Score."

Sirvent P, Mercier J, Vassort G et al. 2005.  Simvastatin triggers mitochondria-induced Ca2+ signaling altercation in skeletal muscle.  Biochem Biophys Res Commun 329:1067-1075.  This article is vitally important for physicians who have patients with myofascial TrPs.  Simvastatin, and, by biochemical inference, statin medications, triggers flood of intra-cellular calcium.  Increased release of Ca2+ is an essential part of the formation of myofascial TrPs, according to Simons’ integrated hypothesis.  The addition of statins could cause a flare of TrP symptoms that would not abate until statins are discontinued.  [This would mesh with personal observations and communications from myofascial pain specialists who have observed that many of their patients do not improve until they are off statins.  DJS]

Sist T, Wong C. 2000.  Difficult problems and their solutions in patients with cancer pain of the head and neck areas.  Curr Rev Pain. 4(3):206-214.  Often, pain in cancer patients is attributed to tumor regrowth when it is due to something else.  These authors urge careful consideration of alternatives and the possibility of mixed pain generators, including myofascial trigger points.

Sist, T., Miner, M.., Lema, M.,. 1999. Characteristics of postradical neck pain syndrome: a report of 25 cases. These results indicate that postoperative neuropathic pain and postoperative TrP pain can be present concurrently, that TrPs can be a common cause of postoperative pain, and that each type of pain requires its own specific treatment for relief.

Sitges C, Garcia-Herrera M, Pericas M et al. 2007.  Abnormal brain processing of affective and sensory pain descriptors in chronic pain patients.  J Affect Disord. [Apr 13 Epub ahead of print]

Sivertsen B, Lallukka T, Salo P et al. 2013. Insomnia as a risk factor for ill health: results from the large population-based prospective HUNT Study in Norway. J Sleep Res. [Oct 30 Epub ahead of print.] "We conclude that insomnia predicts cumulative incidence of several physical and mental conditions. These results may have important clinical implications, and whether or not treatment of insomnia would have a preventive value for both physical and mental conditions should be studied further."

Sivri, A., A. Cindas, F. Dincer and B. Sivri. 1996. Bowel dysfunction and irritable bowel syndrome in fibromyalgia patients. Clin Rheumatol 15(3):283-286.

Skarpsno ES, Nilsen TIL, Sand T et al. 2019. The joint effect of insomnia symptoms and lifestyle factors on risk of self-reported fibromyalgia in women: longitudinal data from the HUNT Study. BMJ Open. 9(8):e028684. "Insomnia symptoms are strongly and positively associated with risk of fibromyalgia in adult women. Leisure time physical activity may compensate for some of the adverse effects of insomnia symptoms on risk of fibromyalgia."

Skootsky, S. A., B. Jaeger and R. K. Oye. 1989. Prevalence of myofascial pain in general internal medicine practice. West J Med 151(2):157-160.

Skorupska E, Dybek T, Rychlik M, et al. A potential objective sign of central sensitization: Referred pain elicited by manual gluteus minimus muscle exploration is coincident with pathological autonomic response provoked by noxious stimulation. Pain Res Manag. 2023 Feb 2;2023:4030622. "Noxious stimulation of latent TrPs induces abnormal autonomic nervous system activity within the referred pain zone. The observed phenomenon supports the concept of central nervous system involvement in the referred pain patomechanizm."

Skorupska E, Rychlik M, Pawelec W et al. 2014. Trigger point-related sympathetic nerve activity in chronic sciatic leg pain: a case study. Acupunct Med. [Jun 26 Epub ahead of print.] "We report the case of a 22-year-old Caucasian European man who presented with a 3-year history of chronic sciatic-type leg pain. In the third year of symptoms, coexistent myofascial pain syndrome was diagnosed. Acupuncture needle stimulation of active trigger points under infrared thermovisual camera showed a sudden short-term vasodilatation (an autonomic phenomenon) in the area of referred pain. The vasodilatation spread from 0.2 to 171.9 cm2 and then gradually decreased.… It is not yet known whether the vasodilatation observed was evoked exclusively by dry needling of active trigger points. The complex condition of the patient suggests that other variables might have influenced the infrared thermovision camera results. We suggest that it is important to check if vasodilatation in the area of referred pain occurs in all patients with active trigger points."

Skorupska E, Rychlik M, Samborski W. 2015. Intensive vasodilatation in the sciatic pain area after dry needling. BMC Complement Altern Med. 15(1):72. "BACKGROUND: Short-term vasodilatation in the pain area after dry needling (DN) of active trigger points (TrPs) was recorded in several cases of sciatica. Moreover, the presence of TrPs in sciatica patients secondary to primary lesion was suggested. Still, it is not known how often they occur and if every TrPs can provoke vasomotor reactions. The purpose of this study was to evaluate the prevalence of active TrPs among subacute sciatica patients and the response to DN under infrared thermovision (IRT) camera control....The presence of active TrPs within the gluteus minimus muscle among subacute sciatica subjects was confirmed. Every TrPs-positive sciatica patient presented DN related vasodilatation in the area of referred pain. The presence of vasodilatation suggests the involvement of sympathetic nerve activity in myofascial pain pathomechanism. Although the clinical meaning of TrPs in subacute sciatica patients is possible, further studies on a bigger group of patients are still required." Free PMC Article

Slater ME, De Lima J, Campbell K et al.  Opioids for the management of severe chronic nonmalignant pain in children: a retrospective 1 year practice survey in a children’s hospital.  Pain Med. [Epub ahead of print]  Function was improved in these children when they received adequate pain control.  Pediatric patients with severe nonmalignant chronic pain should not be denied opioids if they are needed as part of a pain management strategy.

Slipp M, Burnham R. 2017. Medication management of chronic pain: A comparison of 2 care delivery models. Can Pharm J (Ott). 150(2):112-117. "The prevalence of chronic pain is high and increasing. Medication management is an important component of chronic pain management. There is a shortage of physicians who are available and comfortable providing this service. In Alberta (Canada), pharmacists have been granted an advanced scope of practice. Given this empowerment, their availability, training and skill set, pharmacists are well positioned to play an expanded role in the medication management of chronic pain sufferers." This review compared "the effectiveness and cost of a physician-only vs. a pharmacist-physician team model of medication management for chronic nonmalignant pain sufferers….The treatment duration and number of visits were used to calculate cost of care….Both models of medication management resulted in significant and comparable improvements in pain, disability and patient perception of medication effectiveness. Patients in the physician-only group were seen more frequently and at a greater cost. The pharmacist-physician team approach was markedly more cost-effective, and patients expressed a high level of satisfaction with their medication management." Free Article

Sloan P. 2008. Review of oral oxymorphone in the management of pain. Ther Clin Manag 4(4):777-787. Oxymorphone is available in both sustained-release and immediate release forms. This opioid does not have an NSAID or acetaminophen included, and has been successful for relief of chronic pain.

Slocumb, J. C. 1984. Neurological factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am J Obstet Gynecol 149(5):536-43.

Slotkoff, A. T., D. A. Radulovic and D. J. Clauw. 1997. The relationship between fibromyalgia and the multiple chemical sensitivity syndrome. Scand J Rheumatol 26(5):364-367.

Sluka KA, Clauw DJ. 2016. Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience. 338:114-129. "We conclude that fibromyalgia and related disorders are heterogeneous conditions with a complicated pathobiology with patients falling along a continuum with one end a purely peripherally driven painful condition and the other end of the continuum is when pain is purely centrally driven."

Smelt H, Pouwels S, Apers JA et al.2020. Anterior cutaneous nerve entrapment syndrome: Two case reports of the forgotten diagnosis after bariatric surgery. Cureus. Jun 8;12(6):e8499. "Unexplained abdominal pain is an increasing phenomenon after laparoscopic bariatric surgery, with an occurrence of 7.4%. The pain could be explained by the anterior cutaneous nerve entrapment syndrome (ACNES)…. We report the cases of two patients with unexplained abdominal pain after laparoscopic bariatric surgery and a significant delay in the diagnosis of ACNES. In both cases, clinical signs of ACNES were demonstrated by a centralized trigger point in the abdominal wall and specific neuropathic aspects during examination. Both patients were temporary pain-free after a diagnostic local lidocaine injection. A neurectomy was performed in both cases, after which they remained pain-free. There was a significant delay (six months and three years, respectively) in the diagnosis of ACNES, and many additional imaging procedures including a diagnostic laparoscopy were performed…. This case report confirms that the diagnosis of ACNES is still frequently overlooked as a cause of chronic abdominal pain." [When there is ACNES, check for TrPs, including scar TrPs. DJS]

Smith D, Wilkie R, Uthman O et al. 2014. Chronic pain and mortality: a systematic review. PLoS One. 9(6):e99048. "This review showed a mildly increased risk of death in people with chronic pain, particularly from cancer. However, the small number of studies and methodological differences prevented clear conclusions from being drawn. Consistently applied definitions of chronic pain and further investigation of the role of health, lifestyle, social and psychological factors in future studies will improve understanding of the relationship between chronic pain and mortality." Free Article

Smith EK, Magarey M, Argue S et al. 2009.  Muscular load to the therapist’s shoulder during three alternative techniques for trigger point therapy.  J Bodyw Mov Ther. 13(2):171-181.  “While there is evidence that the TTT (treatment-tool technique) decreases the muscular load to the shoulder of the contact arm, there is no indication of where this load is redistributed.”

Smith J.A., Lumley M.A., Longo D.J. 2002.  Contrasting emotional approach coping with passive coping for chronic myofascial pain.  Ann Behav Med 24(4):326-35. Emotional-approach coping (emotional processing and emotional expression) was related to less pain in myofascial pain patients, especially women, and less depression in men.  The use of passive pain coping strategies are associated with worse pain and adjustment.  Some emotion-focused types of pain coping may be adaptive.

Smith JD, Terpening CM, Schmidt SO et al. 2001. Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins.  Ann Pharmacother 35(6):702-706.  A subset of FMS patients may improve significantly with the elimination of excitotoxins such as monosodium glutamate and aspartame from their diet.

Smith L, Wilkinson D, Bodani M et al. 2018. Short-term memory impairment in vestibular patients can arise independently of psychiatric impairment, fatigue, and sleeplessness. J Neuropsychol. [Apr 19 Epub ahead of print] Vestibular dysfunction is associated with visual short-term memory impairment; however, it remains unclear if this impairment arises as a direct result of the vestibular dysfunction or is a consequence of comorbid changes in mood, affect, fatigue, and/or sleep. "The high concurrence of these symptoms gives reason to infer the existence of a vestibular cognitive affective syndrome.... From a rehabilitation perspective, the implication is that if the vestibular disorder is treated successfully then the memory problem will likewise improve." [Vestibular dysfunction is a common and often missed co-existing illness for FM and TrPs. DJS]

Smith MT, Perlis ML, Haythornthwaite JA. 2004.  Suicidal ideation in outpatients with chronic musculoskeletal pain: an exploratory study of the role of sleep onset insomnia and pain intensity.  Clin J Pain. 20(2):111-118.  “Chronic pain patients who self-reported severe and frequent initial insomnia with concomitant daytime dysfunction and high pain intensity were more likely to report passive suicidal ideation, independent from the effects of depression severity.”  More attention needs to be focused on controlling factors leading to suicidal ideation in chronic pain patients.

Smith MT, Edwards RR, Robinson RC et al. 2004.  Suicidal ideation, plans, and attempts in chronic pain patients: factors associated with increased risk.  Pain 111(1-2):201-208.  “These findings highlight the need for routine evaluation monitoring of suicidal behavior in chronic pain, especially for patients with histories of suicide, those taking potentially lethal medications, and patients with abdominal pain.”

Smith MT Jr, Remeniuk B, Finan PH et al. 2018. Sex differences in measures of central sensitization and pain sensitivity to experimental sleep disruption: Implications for sex differences in chronic pain. Sleep. [Oct 29 Epub ahead of print]. Females demonstrate heightened central sensitization (CS), a risk factor for chronic pain characterized by enhanced responsivity of central nervous system nociceptors to normal or subthreshold input. Sleep disruption increases pain sensitivity, but sex has rarely been evaluated as a moderator and few experiments have measured CS. We evaluated whether two nights of sleep disruption alters CS measures of secondary hyperalgesia and mechanical temporal summation in a sex dependent manner. We also evaluated differences in measures of pain sensitivity.... FA (forced awakenings) reduced total sleep time (REM and NREM Stage 3) more profoundly in males. We observed divergent, sex dependent effects of FA on secondary hyperalgesia and temporal summation. FA significantly increased secondary hyperalgesia in males and significantly increased temporal summation in females. Sex differences were not attributable to differential sleep loss in males. FA also significantly reduced heat pain threshold and cold pressor pain tolerance, independently of sex....Sleep disruption enhances different pain facilitatory measures of CS in males and females suggesting that sleep disturbance may increase risk for chronic pain in males and females via distinct pathways.

Smith PF. 2012. Dyscalculia and vestibular function. Med Hypotheses. [Jul 21 Epub ahead of print]. "A few studies in humans suggest that changes in stimulation of the balance organs of the inner ear (the 'vestibular system') can disrupt numerical cognition, resulting in 'dyscalculia', the inability to manipulate numbers. Many studies have also demonstrated that patients with vestibular dysfunction exhibit deficits in spatial memory....It is suggested that there may be a connection between spatial memory deficits resulting from vestibular dysfunction and the occurrence of dyscalculia, given the evidence that numerosity is coupled to the processing of spatial information (e.g., the 'spatial numerical association of response codes ('SNARC') effect')."

Smith PF, Darlington CL. 2013. Personality changes in patients with vestibular dysfunction. Front Hum Neurosci. 7:678. "The vestibular system is a sensory system that has evolved to detect linear and angular acceleration of the head in all planes so that the brain is not predominantly reliant on visual information to determine self-motion. Since the vestibular system first evolved in invertebrate species in order to detect gravitational vertical, it is likely that the central nervous system has developed a special dependence upon vestibular input. In addition to the deficits in eye movement and postural reflexes that occur following vestibular dysfunction, there is convincing evidence that vestibular loss also causes cognitive and emotional disorders, some of which may be due to the reflexive deficits and some of which are related to the role that ascending vestibular pathways to the limbic system and neocortex play in the sense of spatial orientation. Beyond this, however, patients with vestibular disorders have been reported to experience other personality changes that suggest that vestibular sensation is implicated in the sense of self. These are depersonalization and derealization symptoms such as feeling "spaced out", "body feeling strange" and "not feeling in control of self". We propose in this review that these symptoms suggest that the vestibular system may make a unique contribution to the concept of self through information regarding self-motion and self-location that it transmits, albeit indirectly, to areas of the brain such as the temporo-parietal junction (TPJ)." [I have observed that many patients with fibromyalgia and chronic myofascial pain also have co-existing (and often undiagnosed) vestibular dysfunction. This co-existing condition may be a cause of significant symptoms. DJS]

Smith PF, Zheng Y. 2013. From ear to uncertainty: vestibular contributions to cognitive function. Front Integr Neurosci. 7:84. "In addition to the deficits in the vestibulo-ocular and vestibulo-spinal reflexes that occur following vestibular dysfunction, there is substantial evidence that vestibular loss also causes cognitive disorders, some of which may be due to the reflexive deficits and some of which are related to the role that ascending vestibular pathways to the limbic system and neocortex play in spatial orientation. In this review we summarize the evidence that vestibular loss causes cognitive disorders, especially spatial memory deficits, in animals and humans and critically evaluate the evidence that these deficits are not due to hearing loss, problems with motor control, oscillopsia or anxiety and depression. We review the evidence that vestibular lesions affect head direction and place cells as well as the emerging evidence that artificial activation of the vestibular system, using galvanic vestibular stimulation (GVS), can modulate cognitive function."

Smith SC, Wagner MS. 2014. Clinical endocannabinoid deficiency (CECD) revisited: Can this concept explain the therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? Neuro Endocrinol Lett. 35(3):198-201. "Subsequent research has confirmed that underlying endocannabinoid deficiencies indeed play a role in migraine, fibromyalgia, irritable bowel syndrome and a growing list of other medical conditions. Clinical experience is bearing this out. Further research and especially, clinical trials will further demonstrate the usefulness of medical cannabis. As legal barriers fall and scientific bias fades this will become more apparent."

Smith, W. A. 1998. Fibromyalgia Syndrome. Nurs Clin North Am 33(4):653-669.

Smythe HA. 2004.  Fibromyalgia among friends. J Rheumatol 31(4):627-630.  This editorial describes anti-fibromyalgia bias that is blatant in material from some medical authors, in spite of scientific evidence that it is real.  Legal advocates should take note of this. 

Snyder-Mackler L, Barry AJ, Perkins AI et al. 1989.  Effects of helium-neon laser irradiation on skin resistance and pain in patients with trigger points in the neck or back.  Phys Ther. 69(5):336-341.  “The purpose of this double-blind study was to ascertain the effects of helium-neon (He-Ne) laser irradiation on skin resistance and pain in patients with trigger points in the neck or low back.”  “Results indicated a statistically significant increase in skin resistance and a decrease in pain following laser treatment.”

Sohn W. 2001. [The path to pain management on WHO. Step III. Towards a better understanding of the treatment of severe chronic pain] Fortschr Med Orig. 119 Suppl 2:81-89. [German] "Many patients with severe chronic pain continue to receive inadequate treatment. The reason is often a lack of proper communication between patient and physician."

Soin A, Cheng J, Brown L et al. 2008. Functional outcomes in patients with chronic nonmalignant pain on long-term opioid therapy.  Pain Pract. 8(5):379-384."We conclude that judicious use of opioids therapy may lead to improvement in perceived quality of life and certain aspects of functional capacity and daily activities in a highly selected group of patients with CNMP (chronic nonmalignant pain) who have not responded to other therapeutic modalities for over 6 months."

Sok SR, Erien JA, Kim KB. 2003.  Effects of acupuncture therapy on insomnia.  J Adv Nurs 44(4):375-384.  Acupuncture may have a significant effect on insomnia.

Solberg Nes L, Carlson CR, Crofford LJ et al. 2010. Self-regulatory deficits in fibromyalgia and temporomandibular disorders. Pain. [Jun 17 Epub ahead of print]. "Chronic pain conditions such as fibromyalgia (FM) and temporomandibular disorders (TMDs) are accompanied by complex interactions of cognitive, emotional, and physiological disturbances. Such conditions are complicated and draining to live with, and successful adaptation may depend on ability to self-regulate. Self-regulation involves capacity to exercise control and guide or alter reactions and behavior, abilities essential for human adjustment. Research indicates that self-regulatory strength is a limited source that can be depleted or fatigued, however, and the current study aimed to show that patients with FM and TMD are vulnerable to self-regulatory fatigue as a consequence of their condition…. Patients displayed significantly less capacity to persist on the subsequent task compared with controls. In fact, patients exposed to low self-regulatory effort displayed similar low persistence to patients and controls exposed to high self-regulatory effort, indicating that patients with chronic pain conditions may be suffering from chronic self-regulatory fatigue….Impact of chronic pain conditions on self-regulatory effort was mediated by pain, but not by any other factors. The current study suggests that patients with chronic pain conditions likely suffer from chronic self-regulatory fatigue, and underlines the importance of taking self-regulatory capacity into account when aiming to understand and treat these complex conditions. "

Sollmann N, Trepte-Freisleder F, Albers L et al. 2016. Magnetic stimulation of the upper trapezius muscles in patients with migraine - A pilot study. Eur J Paediatr Neurol. [Aug 1 Epub ahead of print.] "BACKGROUND: Repetitive peripheral magnetic stimulation (rPMS) has been applied to musculoskeletal pain conditions. Since recent data show that migraine and tension-type headache (TTH) might be closely related to peripheral muscular pain in the neck and shoulder region (supporting the concept of the trigemino-cervical complex (TCC)), this pilot study explores the acceptance of rPMS to the upper trapezius muscles in migraine (partly in combination with TTH). METHODS: We used rPMS to stimulate active myofascial trigger points (aTrPs) of the upper trapezius muscles in 20 young adults suffering from migraine. Acceptance was assessed by a standardized questionnaire, whereas self-rated effectiveness was evaluated by headache calendars and the Migraine Disability Assessment (MIDAS). Algometry was performed to explore the local effect of rPMS on the muscles. RESULTS: Acceptance of rPMS was shown in all subjects without any adverse events, and rPMS had a statistically significant impact on almost every parameter of the headache calendar and MIDAS. Among others, the number of migraine attacks… and migraine intensity… significantly decreased regarding pre- and post-stimulation assessments. Accordingly, 100.0% of subjects would repeat the stimulation, while 90.0% would recommend rPMS as a treatment option for migraine".

Sørensen K, Christiansen B. 2017. Adolescents' experience of complex persistent pain. Scand J Pain. 15:106-112. "Persistent (chronic) pain is a common phenomenon in adolescents. When young people are referred to a pain clinic, they usually have amplified pain signals, with pain syndromes of unconfirmed ethology, such as fibromyalgia and complex regional pain syndrome (CRPS). Pain is complex and seems to be related to a combination of illness, injury, psychological distress, and environmental factors. These young people are found to have higher levels of distress, anxiety, sleep disturbance, and lower mood than their peers and may be in danger of entering adulthood with mental and physical problems. In order to understand the complexity of persistent pain in adolescents, there seems to be a need for further qualitative research into their lived experiences. The aim of this study was to explore adolescents' experiences of complex persistent pain and its impact on everyday life…. Three main themes were identified: (1) a life with pain and unpleasant bodily expressions; (2) an altered emotional wellbeing; and (3) the struggle to keep up with everyday life. The pain was experienced as extremely strong, emerging from a minor injury or without any obvious causation, and not always being recognised by healthcare providers. The pain intensity increased as the suffering got worse, and the sensation was hard to describe with words. Parts of their body could change in appearance, and some described having pain-attacks or fainting. The feeling of anxiety was strongly connected to the pain. Despair and uncertainty contributed to physical disability, major sleep problems, school absence, and withdrawal from leisure activities. Their parents were supportive, but sometimes more emotionally affected than themselves. The adolescents described how they strived for normality and to not become an outsider. Being met with necessary facilitation from school was important, as well as keeping up with friends. These adolescents had all been treated by an interdisciplinary pain team, and stated that they had an optimistic view of the future, despite still having some symptoms….The study provides new insights into adolescents' own experiences of complex persistent pain occurring unexpectedly, developing dramatically over time, and influencing all parts of their everyday lives. The adolescents entered vicious cycles, with despair and decreased physical and social functioning, with the risk of isolation and role-loss. However, these young people seem to have a strong motivation to strive for normalcy."

Soriano PK, Bhattarai M, Vogler CN et al. 2017. A case of trigger-point injection-induced hypokalemic paralysis. Am J Case Rep. 18:454-457. "A 39-year-old man with no past medical history except for chronic left hip pain from a work-related injury received a TPI with methylprednisolone and bupivacaine. The TPI targeted the left iliopsoas tendon and was administered using ultrasound guidance. There were no immediately perceived complications, but within 12 h he presented with severe hypokalemic paralysis with a serum potassium 1.7 mmol/L. Judicious potassium repletion was initiated. Repeated tests after 6 h consistently showed normal potassium levels of 4.5 mmol/L…. Severe hypokalemic paralysis in the context of trigger-point injection is an incredibly rare occurrence and this is the first case report in English literature." Free Article [One wonders about the selection of such myotoxic injectates. DJS]

Sorond FA, Hurwitz S, Salat De et al. 2013. Neurovascular coupling, cerebral white matter integrity, and response to cocoa in older people. Neurology Aug 7 [Epub ahead of print] Neurovascular coupling is associated with cognitive function. Both can be improved in individuals with impaired cognitive function between the ages of about 67 to 78 if they consume cocoa every day.

Sorrell MR. 2015. Trigger point injection reduces the pain of idiopathic intracranial hypotension. Headache. 55(5):697-699.

Sorrell MR. 2010. Myofascial examination leads to diagnosis and successful treatment of migraine headache. J Musculoskel Pain. 18(1). “The myofascial examination of the head and neck reproduced the headache pain of most patients having migraine. The PTS (physical therapist supervised stretching of involved muscles along their lengths) is effective in treating these headaches. The myofascial examination should be used to determine treatment for migraineurs.” 

Sorrell MR, Flanagan W. 2003. Treatment of chronic resistant myofascial pain using a multidisciplinary protocol [The Myofascial Pain Program].  J Musculoskel Pain 11(1):5-9.  Multidisciplinary treatment including myofascial technique physical therapy, surface electromyography and biofeedback training, medication and trigger point injections can significantly produce pain relief, mood elevation and increase ability to function, even in patients who have symptoms resistant to other therapies.

Sorrell MR, Flanagan W, McCall JL. 2003.  Symptom duration affects the outcome of multidisciplinary treatment of myofascial pain.  The method of assessment influences the understanding of the results.  J Musculoskel Pain 11(1):11-16.  The earlier the patient enters a multidisciplinary treatment program that understands myofascial pain, the better the results.

Sorrell MR, Flanagan W, McCall JL. 2003.  The effect of depression and anxiety on the success of multidisciplinary treatment of chronic resistant myofascial pain.  J Musculoskel Pain 11(1):17-20. Co-existing depression significantly reduced positive outcome of this treatment

Sousa AS, Macedo R, Santos R et al. 2013. Influence of wearing an unstable shoe construction on compensatory control of posture. Hum Mov Sci. 32(6):1353-1364. "These findings demonstrate that WUS (wearing unstable shoes) led to a reorganization of the postural control system associated to improved performance of some components of postural control responses."

Sousa RF, Gazzola JM, Gananca MM et al. 2011. Correlation between the body balance and functional capacity from elderly with chronic vestibular disorders. Braz J Otorhinolaryngol. 77(6):791-798. [Article in English, Portuguese] "Vestibular disorders are common among the elderly, mainly resulting in dizziness and imbalance - symptoms which can impact daily routine activities.....There is a positive correlation between body balance and functional capacity in elderly patients with peripheral vestibular disorders, that is: the better the balance, the better the individual's functional capacity. In addition, a worse functional capacity increases the individual's risk of falling." [Vestibular dysfunction is also common in FM patients, and must be considered. DJS]

Southwick, S. M., C. A. Morgan 3^rd, D. S. Charney and J. R. High. 1999. Yohimbine use in a natural setting: effects on posttraumatic stress disorder. Biol Psychiatry 46(3):442-4.

Souza-Silva E, Ascenso R, Carlos Tonussi C R, et al. 2021. Detection of blood flow perfusion and post - occlusive reactive hyperemia in the skeletal muscle of rats. Life Sci. 2021 May 5;278:119571. Online ahead of print. "We demonstrated that the profile of PORH in the anterior tibialis muscle of rats is sensitive to a variety of experimental models often associated with the skeletal muscle functionality, providing a useful strategy to explore how and whether changes in local regulation of blood flow can contribute to the development of skeletal muscle associated symptoms in clinically relevant conditions."

Soyupek F, Soyupek S, Akkus S et al. 2007.  The coexistence of the fibromyalgia syndrome and the overactive bladder syndrome.  J Musculoskel Pain 15(3):31-37.  “Our findings suggest that there is an association between OBS and FMS, especially in female patients.”  The authors remind readers that both FM and OBS are chronic.

Soyupek F, Yildiz S, Akkus S et al. 2010. The frequency of fibromyalgia syndrome in patients with polycystic ovary syndrome. J Musculoskel Pain 18(2):120-126. This interesting article reports that 32% of FM patients in the study had polycystic ovary syndrome (PCOS). Only 7.7% of the healthy controls had PCOS. Insulin resistance is a common co-existing condition in FM patients, and PCOS is common in insulin resistance. It would be most interesting to learn what percentage of these patients also had insulin resistance. It is suspected that FM and insulin resistance are interactive diagnoses. DJS]

Spaeth M, Alegre C, Perrot S et al. 2013. Long-term tolerability and maintenance of therapeutic response to sodium oxybate in an open-label extension study in patients with fibromyalgia. Arthritis Res Ther. 15(6):R185. "The long-term safety and therapeutic response of sodium oxybate (SXB) in fibromyalgia syndrome (FM) patients were assessed for a combined period of up to 1 year in a prospective, multicenter, open-label, extension study in patients completing 1 of 2 phase 3 randomized, double-blind, controlled, 14-week trials that examined the efficacy and safety of SXB 4.5 g, SXB 6 g, and placebo for treatment of FM….Maintenance of SXB therapeutic response was demonstrated with continued improvement from controlled-study baseline in pain VAS, Fibromyalgia Impact Questionnaire (FIQ) total scores, and other measures. Responder analyses showed that 68.8% of patients achieved ≥ 30% reduction in pain VAS and 69.7% achieved ≥ 30% reduction in FIQ total score at study endpoint….The long-term safety profile of SXB in FM patients was similar to that in the previously reported controlled clinical trials. Improvement in pain and other FM clinical domains was maintained during long-term use."

Spaeth M. 2011. [Fibromyalgia]. Z Rheumatol. 70(7):573-587. [German]. "Although chronic musculoskeletal pain represents the main symptom of fibromyalgia, those affected usually experience many and various accompanying symptoms of differing frequency and extent. While symptoms such as non-restful sleep, daytime fatigue, impaired memory and concentration, morning stiffness, as well as digestive and urination disorders help to establish the diagnosis, they represent a particular disease burden on patients, those around them and on the social system. Pathogenetic research is focused increasingly on a central dysregulation in pain perception and pain processing, leading to the concept of 'central sensitization' as a final common pathway for fibromyalgia and similar syndromes. This supports the recommendations for prompt multimodal therapy based on pharmaco-, functional and behavioral therapy."

Spaeth M. 2010. Fibromyalgia syndrome treatment from a multidimensional perspective. J Musculoskel Pain. 18(4):373-379. "Fibromyalgia syndrome (FMS) is a pain syndrome which is not due to tissue damage or inflammation, and is thus fundamentally different from rheumatic disorders and many other pain conditions. Presenting as a 'prototype' of a 'central pain' disease, FMS widespread pain is often associated with a wide range of other symptoms such as sleep disturbance, fatigue, cognitive disturbance, stiffness, and depressive symptoms. The underlying mechanisms involved in the development of central sensitization both explain the clinical variety of symptoms (heterogeneity) and provide targets for pharmacologic and nonpharmacologic treatment strategies." "Nonpharmacologic therapies include education, exercise, cognitive behavioral therapy, and other multidimensional therapeutic approaches. These should enable the patient to develop his or her own disease management strategies, in which drugs can be incorporated. Pharmacologic treatment targets several mechanisms involved in the development of central sensitization." "The role of nonrestorative, unrefreshing sleep has been underestimated for many years. Recently, clinical trials have been published, emphasizing the important role of improved sleep quality. There was significant benefit on many disease domains by giving sodium oxybate. The complex symptomatology of FMS will continue to require a multidisciplinary approach including education and exercise, in addition to drug therapy to achieve the most efficient management of FMS, thus indicating a strong need for further and more extended studies targeting the benefits from using combinations of pharmacologic and nonpharmacologic treatments….Comorbid mood and anxiety disorders have often led to the misconception that FMS is a pure psychiatric illness. Now there is increasing evidence that FMS subgroups exist, presenting with a broad variety of different comorbidities and a varying extent of these comorbidities." "There is increasing evidence that nonrestorative sleep and its influence on peripheral functions promote hyperalgesia, fatigue and bodily hypersensitivity….The fragmentation of slow-wave sleep increases sensitivity to pain as well as to nonpainful stimuli such as loud sounds and bright light. Fragmented sleep is a result of periodic arousal disturbances and has been demonstrated in FMS patients using polysomnography; the high index of such arousal disturbances in FMS patients is an indicator of sleep instability and is associated with unrefreshing, less efficient sleep, and is correlated to the severity of clinical symptoms in FMS patients….Neurotransmitter functions and dysfunctions in FMS patients also contribute to hypersensitivity and disordered sleep. Sodium oxybate increases slow-wave sleep decreases alpha intrusions into nonrapid eye movement slow-wave sleep and reduces pain and fatigue associated with FMS. The most recent study with sodium oxybate in FMS could demonstrate significant improvement in a composite score including pain, rated on a visual analog scale, the fibromyalgia impact questionnaire score, and patient global assessment." [It is extremely sad, seeing the evidence supporting the ability of sodium oxybate to provide restorative, refreshing sleep, that the FDA has denied its use for FM patients. The denial was due to admitted fear that it would be abused by patients who might sell it for use as a date-rape drug rather than use it. That is quite a commentary on our focus on the "War on Drugs," which, in this instance, has become a "War on Chronic Pain Patients." They say they need more studies. Perhaps they should read this article. DJS]

Spaeth M. 2009.  Epidemiology, costs, and the economic burden of fibromyalgia.  Arthritis Res Ther. 11(3):117.  “Despite the differences between healthcare and sociopolitical systems in various countries, more recent results from epidemiological research now clearly demonstrate the socioeconomic burden of fibromyalgia and its comorbidities.  The costs of the disease, calculated in single studies and countries, allow estimates for populations in other countries.  The alarming results highlight the urgent need both for more research (including pathophysiology and epidemiology) and for the acceptance of emerging treatment challenges.”  [The central sensitization of fibromyalgia occurs worldwide, and is a significant burden on the patient and the health care system.  Most cases of FM are preventable.  It’s long past time for the medical community to devote resources to research and vigorous treatment, rather than wasting resources in denying the existence of FM. DJS]

Spaeth M, Bennett RM, Benson BA et al. 2012. Sodium oxybate therapy provides multidimensional improvement in fibromyalgia: results of an international phase 3 trial. Ann Rheum Dis. [Jan 31 Epub ahead of print]. "Along with pain and fatigue, non-restorative sleep is a core symptom of fibromyalgia." This study of 573 FM patients meeting the 1990 ACR criteria... .."were randomly assigned to placebo, SXB (sodium oxybate) 4.5 g/night or SXB 6 g/night." Assessment included pain, ..."function, sleep quality, effect of sleep on function, fatigue, tenderness, health-related quality of life and subject's impression of change in overall wellbeing....Significant improvements in pain, sleep and other symptoms associated with fibromyalgia were seen in SXB treated subjects compared with placebo....These results, combined with findings from previous phase 2 and 3 studies, provide supportive evidence that SXB therapy affords important benefits across multiple symptoms in subjects with fibromyalgia.

Spaeth M, Rizzi M, Sarzi-Puttini P. 2011. Fibromyalgia and sleep. Best Pract Res Clin Rheumatol. 25(2):227-239. "Chronic pain in fibromyalgia patients, together with its associated symptoms and co-morbidities, is now considered a result of dysregulated mechanisms in the central nervous system (CNS). As fibromyalgia patients often report sleep problems, the physiological processes that normally regulate sleep may be disturbed and overlap with other CNS dysfunctions. Although the mechanisms potentially linking chronic widespread pain, sleep alterations and mood disorders have not yet been proven, polysomnography findings in patients with fibromyalgia and non-restorative sleep and their relationships with clinical symptoms support the hypothesis of a conceptual common mechanism called 'central sensitization'. Food and Drug Administration (FDA)-approved drugs for the treatment of fibromyalgia may benefit sleep, but their label does not include the treatment of fibromyalgia-associated sleep disorders. Non-pharmacological therapies (including a thorough sleep assessment) can be considered in the first-line treatment of non-restorative sleep, although they have not yet been fully investigated in patients with fibromyalgia. Both pharmacological and non-pharmacological treatments should be used cautiously in patients with fibromyalgia, bearing in mind the patients' underlying disorders and the potential interactions of the therapies."

Spaggiari, M. C., F. Granella, L. Parrino, C. Marchesi, I. Melli and M. G. Terzano. 1994. Nocturnal eating syndrome in adults. Sleep 17(4):339-44.

Spahn V., Del Vecchio G, Labuz D et al. A nontoxic pan killer designed by modeling of pathological receptor conformations. Science 355(6328):966-969. There is a great need for pain relief without the side-effects. Pain driven by the peripheral nervous system is characterized by acidic tissue and cellular inflammation. This research, unlike previous research for compounds to provide pain relief, has focused on an acidic environment, which is prevalent in biochemical inflammation in tissue. An acidic environment up-regulates mu opioid receptors and their signaling pathways and changes critical parts of the cellular metabolic environment. This study used computer simulations taking into account acidic tissue environment closer to pathological pain-producing states. An opioid receptor agent that would bind in acidic tissue and work on peripheral pain generating sites without the central nervous system and intestinal side-effect found in conventional pain relievers. A study in rats using a variety of inflammatory pain found this agent (NFEPP), developed in Berlin, to be a successful analgesic compared to fentanyl,"… without exhibiting respiratory depression, sedation, constipation, or addiction potential." [This holds hope for future myofascial trigger point relief, and relief of other pain maintaining or causing the central nervous system hypersensitivity of fibromyalgia. Trigger points do cause acidic tissue environment. DJS]

Spath M, Neeck G. 2002.  [The expert assessment of fibromyalgia.]  Z Rheumatol 61(6):661-6. [German]   Pain amplification syndromes are well documented and have been researched for a decade.  The validity of the reality of fibromyalgia has no place in an expert assessment.  “The sociomedical implications (of fibromyalgia) are obvious and considerable...”  Assessments must be specific to the individual, focusing on evaluation of specific impairments and disabilities and how these handicaps affect function.

Spector JA, Singh SP, Karp NS. 2008. Outcomes after breast reduction: does size really matter? Ann Plast Surg. 60(5):505-509. "This study demonstrates that women seeking breast reduction have a similar preoperative symptom burden across a wide range of breast sizes. Furthermore, the symptomatic improvement derived from RM is not significantly different between women of different breast sizes."

Sperber AD, Dekel R. 2010. Irritable Bowel Syndrome and Co-morbid Gastrointestinal and Extra-gastrointestinal Functional Syndromes. J Neurogastroenterol Motil. 16(2):113-119. "Many IBS patients have at least one co-morbid somatic complaint and many meet diagnostic criteria for other functional disorders. Patients with IBS and another functional disorder, in comparison with patients with IBS only, have more severe IBS symptoms, a higher rate of psychopathology, greater impairment of quality of life, and more illness-related work absenteeism. Estimates of the prevalence of IBS in patients with fibromyalgia range from 30-35% to as high as 70%. Studies of IBS among patients with chronic fatigue syndrome have reported a prevalence ranging from 35-92%.....It has been suggested that the presence of multiple co-morbid disorders may be a marker for psychological influences on etiology. This raises the question of whether the functional syndromes represent the same pathophysiological process, i.e., are the same entity that has been separated into different clinical entities because of medical sub-specialization, or are indeed separate disorders. While the answer to this question awaits further research, it would appear that most functional patients who meet formal diagnostic criteria for more than one functional disorder manifest one disorder clinically more that the others and seek consultation differentially for that set of symptoms.

Spevak C. 1997.  Asystole during trigger point injections in a patient with panic disorder.  Reg Anesth. 22(6):583.  [This article is a vital reminder that TrP injections can be painful and complex, and that it takes more than a glance at a TrP diagram to be able to perform them adequately.  Patients must be carefully assessed and pain and anxiety must be brought under control, and the protocol followed, with the pain and anxiety level kept below danger level.  One must always monitor for symptoms of shock or other severe reaction and be ready to handle whatever may come.  The best preventative is a well-educated and prepared patient and care provider.  DJS]

Spitzer AR, Boyle JT, Tuchman DN et al. 1984.  Awake apnea associated with gastroesophageal reflux: a specific clinical syndrome.  J Pediatr 104(2):200-205.

Spitzer AR, Broadman M. 2010. Treatment of the narcoleptiform sleep disorder in chronic fatigue syndrome and fibromyalgia with sodium oxybate. Pain Pract. 10(1):54-59. "Sixty percent of patients treated with oxybate experienced significant relief of pain, while 75% experienced significant relief of fatigue. We postulate that the response to oxybate in CFS and FM suggests a disturbance of sleep similar to narcolepsy. These findings support this novel approach to intervention and further research."

Spitznagle TM, McCurdy Robinson C. 2014. Myofascial Pelvic Pain. Obstet Gynecol Clin North Am. 41(3):409-432. "Individuals with pelvic pain commonly present with complaints of pain located anywhere below the umbilicus radiating to the top of their thighs or genital region. The somatovisceral convergence that occurs within the pelvic region exemplifies why examination of not only the organs but also the muscles, connective tissues (fascia), and neurologic input to the region should be performed for women with pelvic pain. The susceptibility of the pelvic floor musculature to the development of myofascial pain has been attributed to unique functional demands of this muscle. Conservative interventions should be considered to address the impairments found on physical examination."

Sprott H, Salemi S, Gay RE et al. 2004.  Increased DNA fragmentation and ultrastructural changes in fibromyalgic muscle fibres.  Ann Rheum Dis. 63(3):245-251.  This study found a significantly high rate of DNA fragmentation in FMS patient samples (55.4%) compared with healthy controls (4.1%).  Myofibers and actin filaments were disorganized, and the number of mitochondria were significantly lower in FMS patients.

Srbely JZ, Dickey JP, Bent LR et al. 2009.  Capsaicin-induced central sensitization evokes segmental increases in trigger point sensitivity in humans.  J Pain. [Dec 14 Epub ahead of print]  “This study investigated whether inducing central sensitization evokes segmental increases in trigger point pressure sensitivity.”  “These results demonstrate that increases in central sensitization evoke increases in trigger point pressure sensitivity in segmentally related muscles.”  “Myofascial pain is the most common form of musculoskeletal pain.  Myofascial trigger points play an important role in the clinical manifestation of myofascial pain syndrome.  Elucidating the role of central sensitization in the pathophysiology of trigger points is fundamental to developing optimal strategies in the management of myofascial pain syndrome.”

Srbely JZ, Dickey JP. 2007.  Randomized controlled study of the anti-nociceptive effect of ultrasound on trigger point sensitivity: novel applications in myofascial therapy?  Clin Rehabil. 21(5):411-417.   “Ultrasound may be a useful clinical tool for the treatment and management of trigger points and myofascial pain syndromes.”

Srbely JZ, Dickey JP, Lee D et al. 2010. Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. J Rehabil Med. 42(5):463-468. "One intervention of dry needle stimulation to a single trigger point (sensitive locus) evokes short-term segmental anti-nociceptive effects. These results suggest that trigger point (sensitive locus) stimulation may evoke anti-nociceptive effects by modulating segmental mechanisms, which may be an important consideration in the management of myofascial pain."

Srbely JZ, Vernon H, Lee D et al. 2013. Immediate effects of spinal manipulative therapy on regional antinociceptive effect in myofascial tissues in healthy young adults. J Manipulative Physiol Ther. 36(6):333-341. This study had as its participants healthy students from Guelph University with identifiable (assumedly latent) trigger points in the infraspinatus and gluteus medius myofascia. They tested the effects on pain sensitivity in these muscles after one single high-velocity, low amplitude rotary spinal thrust spinal manipulative therapy on the C5-C6. The treatment resulted in short-term increases in pain sensitivity in the muscles tested. This did not occur in students in a control group who received sham treatment. [The effects on pain sensitivity in the buttocks and shoulder after a chiropractic technique performed on the spinal area of the neck (in healthy students who probably had latent trigger points) are interesting. I'd like to see a study with comparison of Activator and manual techniques compared, using patients with active trigger points in the same muscles, including patients who have central sensitization. DJS]

Srdic, F., Sarhus, M., Topuz, O. 2002.  Comparisons of two different techniques of electrotherapy on myofascial pain.  J Back Musculoskel Rehab 16:11-16.  Electrotherapy can be useful to treat myofascial pain.

Srinivasan AK, Kaye JD, Moldwin R. 2007.  Myofascial dysfunction associated with chronic pelvic floor pain: management strategies.  Curr Pain Headache Rep. 11(5):359-364.

Stahlberg L, Palmquist E, Nordin S. 2016. Intolerance to environmental chemicals and sounds in irritable bowel syndrome: Explained by central sensitization? J Health Psychol. [Jul 7 Epub ahead of print.] "This study tested the hypotheses of irritable bowel syndrome showing (1) comorbidity with chemical and sound intolerance, other types of functionally somatic syndromes, and psychiatric disorders and (2) stronger than normal affective reactions to and behavioral disruptions from odorous/pungent chemicals and sounds in daily life. These hypotheses were tested by means of data from a large-scale population-based questionnaire study. The results showed comorbidity in irritable bowel syndrome with chemical and sound intolerance, fibromyalgia, migraine, post-traumatic stress disorder, generalized anxiety disorder, panic syndrome, and depression as well as strong reactions/disruptions from odorous/pungent chemicals and sounds in irritable bowel syndrome."

Stamer UM, Bayerer B, Stuber F. 2005.  Genetics and variability in opioid response.  Eur J Pain. 9(2):101-104.  “In pain therapy, the genetic background influencing the efficacy of opioid therapy is of special interest.  CYP2D6 genetic variability is supposed to be a major factor of adverse drug reaction, possibly influencing hospital stay and total costs.  Further candidate genes involved in pain perception, pain processing and pain management like opioid receptors, transporters and other targets of pharmacotherapy are under investigation.  Aspects of genetic differences influencing efficacy, side effects and adverse outcome of pharmacotherapy will be of importance for future pain management.”

Stander S, Schmelz M. 2006.  Chronic itch and pain – similarities and differences.  Eur J Pain [May 4 Epub ahead of print]  “Classical inflammatory mediators such as bradykinin have been shown to sensitize nociceptors for both itch and pain.  Also regulation of gene expression induced by trophic factors, such as NGF, plays a major role in persistently increased neuronal sensitivity for itch and pain.  Finally, itch and pain exhibit corresponding patterns of central sensitization.”

Stander S, Steinhoff M, Schmetz M et al. 2003.  Neurophysiology of pruitis: cutaneous elicitation of itch.  Arch Dermatol 139(11):1463-1470. This article is important because it indirectly explains how itch can be a manifestation of both fibromyalgia and/or myofascial pain.  It covers receptor systems, itch generation by both peripheral and central nervous systems, as well as mechanical, chemical (including biochemical) triggers. This paper may be of help in documenting itch associations with the above-mentioned conditions.

Starlanyl DJ. 2006. Comment on Canadian consensus document on fibromyalgia syndrome.  J Musculoskel Pain. 14(4):75-81.  In the original document, there seemed to be confusion between symptoms due to FMS and those that were due to co-existing myofascial TrPs.  This offers clarifications.

Starlanyl DJ, Jeffrey JL, Roentsch G, Taylor-Olson C. 2001-02. The effect of transdermal T3 (3,3’,5-triiodothyronine) on geloid masses found in patients with both fibromyalgia and myofascial pain: double-blinded, N of 1 clinical study.  Myalgies.2(2):8-18.

Starlanyl, D.  T’ai Chi Chuan and Musculoskeletal Pain.  T’ai Chi Magazine.  [Accepted for publication July 2001.]

Starlanyl DJ and Jeffrey JL. 2001.  The presence of geloid masses in a patient with both fibromyalgia and chronic myofascial pain. Phys Ther Case Rep 4(1):22-31.

Starlanyl D. J. and M. E. Copeland. 2001. Fibromyalgia and Chronic Myofascial Pain: A Survival Manual. Edition 2. Oakland: New Harbinger Publications.

Starlanyl DJ. 1999. The Fibromyalgia Advocate. Oakland: New Harbinger Publications.

Starlanyl D J 1997. Chronic Myofascial Pain Syndrome: A Guide to the Trigger Points. Oakland: New Harbinger. 2 hour video.

Starlanyl DJ. 1997.  Fibromyalgia and Myofascial Pain Syndrome: A Special Challenge.  Clin Bull Myofas Ther 2 (2/3): 75-89.

Starlanyl DJ. 1995.  "Comment on Granges and Littlejohn's. "Prevalence of myofascial pain syndrome in fibromyalgia and regional pain syndrome: A comparative study."  J Musculoskel Pain 3 (1):129-132.

Starlanyl DJ 1994.  "Comment on article by Hong, Chen, Pon and Yu, "Intermediate effects of various physical medicine modalities on pain threshold of an active myofascial trigger point."  J Musculoskel Pain 2 (2):141-142.

Staud R. 2022. Advances in the management of fibromyalgia: what is the state of the art? Expert Opin Pharmacother. May 4;1-11. "Currently approved pharmacological therapies for FM symptoms have limited but proven effectiveness. Novel therapies with cannabinoids and naltrexone appear promising. Recent functional imaging studies of FM have discovered multiple brain network abnormalities that may provide novel targets for mechanism-based therapies. Future treatment approaches, however, need to improve more than clinical pain but also other FM domains like fatigue, insomnia, and distress."

Staud R. 2018. Tai chi reduced severity of fibromyalgia symptoms at 24 weeks compared with aerobic exercise. Ann Intern Med. 168(12):JC70.

Staud R. 2015. Cytokine and Immune System Abnormalities in Fibromyalgia and Other Central Sensitivity Syndromes. Curr Rheumatol Rev. 11(2):109-115. "The nervous system as well as the immune system use common signaling molecules for intra- and inter-system communications. Specifically, both entities produce a similar array of peptide and non-peptide transmitters that act on a common set of receptors present in the two systems. One important set of such signaling molecules are cytokines. The wide distribution of cytokine receptors throughout the body, including the immune and the nervous system allows direct communication between these two entities. In addition to cytokines the nervous system and immune system also communicate with each other using shared ligands such as neurotransmitters and neuroendocrine hormones, and their respective receptors. Some of the most important clinical interactions between these two systems are associated with the 'sickness response' as well as pain and analgesia. This 'sickness response' which has been frequently attributed to inflammatory cytokines, strongly resembles the core symptoms of fibromyalgia and other Central Sensitivity Syndromes (CSS). Therefore a large number of research studies have focused on the relationship between peripheral cytokines and CSS. However, a lack of consistent associations was observed between CSS symptoms and peripheral cytokines which seem to suggest that maybe cytokines abnormalities of the central nervous system contribute to the pathogenesis of these illnesses. Better knowledge of cytokine -nervous system interactions may ultimately benefit the development of interventions that improve CSS manifestations including the 'sickness response' and chronic pain."

Staud R. 2013. The important role of CNS facilitation and inhibition for chronic pain. Int J Clin Rheumtol. 8(6):639-646. "Multiple studies have demonstrated that the pain experience among individuals is highly variable. Even under circumstances where the tissue injuries are similar, individual pain experiences may vary drastically. However, this individual difference in pain sensitivity is not only related to sensitivity of peripheral pain receptors, but also to variability in CNS pain processing. Peripheral impulses derived from tissue receptors undergo modification in dorsal horn neurons that can either result in inhibition or facilitation of pain. Such influences are particularly apparent in inflammation where not only peripheral, but also central, pain modulatory mechanisms can significantly increase nociceptive pain. Emotional state, level of anxiety, attention and distraction, memories, stress, fatigue and many other factors can either increase or reduce the pain experience. Increasing evidence suggests that 'bottom-up' and 'top-down' modulatory circuits within the spinal cord and brain play an important role in pain processing, which can profoundly affect the experience of pain."

Staud R. 2012. Peripheral and Central Mechanisms of Fatigue in Inflammatory and Noninflammatory Rheumatic Diseases. Curr Rheumatol Rep. [Jul 17 Epub ahead of print]. "Whereas many studies have focused on disease activity as a correlate to these patients' fatigue, it has become apparent that other factors, including negative affect and pain, are some of the most powerful predictors for fatigue. Conversely, sleep problems, including insomnia, seem to be less important for fatigue. There are several effective treatment strategies available for fatigued patients with rheumatologic disorders, including pharmacological and nonpharmacological therapies."

Staud R. 2011. Evidence for Shared Pain Mechanisms in Osteoarthritis, Low Back Pain, and Fibromyalgia. Curr Rheumatol Rep. [Aug 11 Epub ahead of print]. "Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM) are common chronic pain disorders that occur frequently in the general population. They are a significant cause of dysfunction and disability. Why some of these chronic pain disorders remain localized to few body areas (OA and LBP), whereas others become widespread (FM), is unclear at this time. Genetic, environmental, and psychosocial factors likely play an important role...... Ineffective endogenous pain control and central sensitization are important features of OA, LBP, and FM patients."

Staud R. 2011. Sodium oxybate for the treatment of fibromyalgia. Expert Opin Pharmacother. [Jun 16 Epub ahead of print]. "Introduction: Gamma-hydroxybutyrate (GHB) is a short-chain fatty acid that is synthesized within the CNS, mostly from its parent compound gamma amino butyric acid (GABA). GHB acts as a neuromodulator/neurotransmitter to affect neuronal activity of other neurotransmitters and so, stimulate the release of growth hormone. Its sodium salt (sodium oxybate: SXB) was approved by the Food and Drug Administration (FDA) for the treatment of narcolepsy. SXB has shown to improve disrupted sleep and increase NR3 (slow-wave restorative) sleep in patients with narcolepsy. It is rapidly absorbed and has a plasma half-life of 30 - 60 min, necessitating twice-nightly dosing. Most of the observed effects of SXB result from binding to GABA-B receptors. Areas covered: Several randomized, controlled trials demonstrated significantly improved fibromyalgia (FM) symptoms with SXB. As seen in narcolepsy trials, SXB improved sleep of FM patients, increased slow-wave sleep duration as well as delta power, and reduced frequent night-time awakenings. Furthermore, FM pain and fatigue was consistently reduced with nightly SXB over time. Commonly reported adverse events included headache, nausea, dizziness and somnolence. Despite its proven efficacy, SXB did not receive FDA approval for the management of FM in 2010, mostly because of concerns about abuse. Expert opinion: Insomnia, fatigue and pain are important clinical FM symptoms that showed moderate improvements with SXB in several large, well-designed clinical trials. Because of the limited efficacy of currently available FM drugs additional treatment options are needed. In particular, drugs like SXB - which belong to a different drug class than other Food and Drug Administration (FDA)-approved FM medications such as pregabalin, duloxetine and milnacipran - would provide a much-needed addition to presently available treatment options. However, the FDA has set the bar high for future SXB re-submissions, with requirements of superior efficacy and improved risk mitigation strategies. At this time, no future FDA submission of SXB for the fibromyalgia indication is planned."

Staud R. 2011. Peripheral pain mechanisms in chronic widespread pain. Best Pract Res Clin Rheumatol. 25(2):155-164. "Clinical symptoms of chronic widespread pain (CWP) conditions like fibromyalgia (FM), include pain, stiffness, subjective weakness, and muscle fatigue. Muscle pain in CWP is usually described as fluctuating and often associated with local or generalized tenderness (hyperalgesia and/or allodynia). This tenderness related to muscle pain depends on increased peripheral and/or central nervous system responsiveness to peripheral stimuli, which can be either noxious (hyperalgesia) or non-noxious (allodynia). For example, patients with muscle hyperalgesia will rate painful muscle stimuli higher than normal controls, whereas patients with allodynia may perceive light touch as painful, something that a 'normal' individual will never describe as painful. The pathogenesis of such peripheral and/or central nervous system changes in CWP is unclear, but peripheral soft tissue changes have been implicated. Indirect evidence from interventions that attenuate tonic peripheral nociceptive impulses in patients with CWP syndromes like FM suggest that overall FM pain is dependent on peripheral input. More importantly, allodynia and hyperalgesia can be improved or abolished by removal of peripheral impulse input. Another potential mechanism for CWP pain is central disinhibition. However, this pain mechanism also depends on tonic impulse input, even if only inadequately inhibited. Thus, a promising approach to understanding CWP is to determine whether abnormal activity of receptors in deep tissues is fundamental to the development and maintenance of this chronic pain disorder.....Most CWP patients present with focal tissue abnormalities including myofascial trigger points, ligamentous trigger points or osteoarthritis of the joints and spine. While not predictive for the development of CWP, these changes nevertheless represent important pain generators that may initiate or perpetuate chronic pain. Local chemical mediators, including lactic acid, adenosine triphosphate (ATP) and cytokines, seem to play an important role in sensitizing deep tissue nociceptors of CWP patients. Thus, the combination of peripheral impulse input and increased central pain sensitivity may be responsible for widespread chronic pain disorders including FM."

Staud R. 2010. Is It All Central Sensitization? Role of Peripheral Tissue Nociception in Chronic Musculoskeletal Pain. Curr Rheumatol Rep. [Sep 30 Epub ahead of print]. "Fibromyalgia syndrome (FM) is a highly prevalent musculoskeletal disorder that is often accompanied by somatic hyperalgesia (enhanced pain from noxious stimuli). Neural mechanisms of somatic hyperalgesia have been analyzed via quantitative sensory testing of FM patients. Results of these studies suggest that FM pain is associated with widespread primary and secondary cutaneous hyperalgesia, which are dynamically maintained by tonic impulse input from deep tissues and likely by brain-to-spinal cord facilitation. Enhanced somatic pains are accompanied by mechanical hyperalgesia and allodynia in FM patients as compared with healthy controls. FM pain is likely to be at least partially maintained by peripheral impulse input from deep tissues. This conclusion is supported by results of several studies showing that injection of local anesthetics into painful muscles normalizes somatic hyperalgesia in FM patients." [This work agrees with the research showing the FM patients have TrPs, and that TrP-pain generation is a common factor sustaining central sensitization. DJS]

Staud R. 2010. Pharmacological treatment of fibromyalgia syndrome: new developments.  Drugs. 70(1):1-14.  “Duloxetine and milnacipran, two highly selective serotonin-norepinephrine (noradrenaline) reuptake inhibitors, and the alpha(2)delta agonist pregabalin have been approved by the US FDA for the treatment of fibromyalgia symptoms.  In general, about half of all treated patients seem to experience a 30% reduction of symptoms, suggesting that many patients with fibromyalgia will require additional therapies.  Thus, other forms of treatment, including exercise, cognitive behavioral therapies and self-management strategies, may be necessary to achieve satisfactory treatment outcomes.  Despite promising results of pilot trials, RCTs (randomized controlled trials) with dopamine receptor agonists and sodium channel antagonists have so far been disappointing for patients with fibromyalgia.  However, new pharmacological approaches for the treatment of fibromyalgia pain and insomnia using sodium oxybate appear to be promising.”

Staud R. 2009.  Abnormal pain modulation in patients with spatially distributed chronic pain: fibromyalgia.  Rheum Dis Clin North Am. 35(2):263-274.  “Many chronic pain syndromes are associated with hypersensitivity to painful stimuli and with reduced endogenous pain inhibition.  These findings suggest that modulation of pain-related information may be linked to the onset or maintenance of chronic pain.  The combination of heightened pain sensitivity and reduced pain inhibition seems to predispose individuals to greater risk for increased acute clinical pain.  It is unknown whether such pain processing abnormalities may also place individuals at increased risk for chronic pain.”

Staud R. 2008. Heart rate variability as a biomarker of fibromyalgia syndrome.  Fut Rheumatol. 3(5):475-483. “HRV (heart rate variability) has been shown to correlate with FM pain and is sensitive to change; in particular, pain related to physical and mental stressors.  Thus, ANS (autonomic nervous system) dysfunction as assessed by HRV analysis may serve as a useful biomarker, and may become part of future FM diagnostic criteria and serve as a surrogate end point in clinical trials.”

Staud R. 2007.  Mechanisms of acupuncture analgesia: effective therapy for musculoskeletal pain?  Curr Rheumatol Rep. 9(6):473-481.    Acupuncture relief may take some time “...to develop and resolve."  “…some forms of AP are more effective for providing analgesia than others.”  Particularly, electro-AP seems best to activate powerful opioids and non-opioid analgesic mechanisms.”

Staud R. 2007.  The role of peripheral input for chronic pain syndromes like fibromyalgia.  J Musculoskel Pain 15 (Supp 13):7 item 8.  [Myopain 2007 Poster]  Indications are that the diffuse, bodywide pain of FM is maintained by peripheral pain stimuli.  “Most FMS patients present with focal tissue abnormalities including myofascial trigger points [TrPs], ligamentous trigger points, or osteoarthritis of the joints and spine.  While not predictive for the development of FMS, these changes nevertheless represent important pain generators that may initiate or perpetuate chronic pain.  Thus spatially limited forms of musculoskeletal pain, including MPS, may develop in some patients into widespread chronic pain syndromes like FMS.”

Staud R. 2006.  Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome.  Arthritis Res Ther. 8(3):208  “Many recent studies have emphasized the role of central nervous system pain processing abnormalities in FM, including central sensitization and inadequate pain inhibition.  However, increasing evidence points towards peripheral tissues as relevant contributors of painful impulse input that might either initiate or maintain central sensitization, or both.  It is well known that persistent or intense nociception can lead to neuroplastic changes in the spinal cord and brain, resulting in central sensitization and pain.   “Importantly, after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state.”

Staud R. 2004.  Fibromyalgia pain: do we know the source? Curr Opin Rheumatol 16(2):157-63.  This review brings together studies that show that the mechanism behind FMS may be biochemicals released due to acute or repetitive injury (traumatic or biochemical) “...may be responsible for long-term activation of spinal cord glia and dorsal horn neurons, thus resulting in central sensitization.”  This conceptual understanding may aid us in discovering more effective therapies and treatment strategies in the future.  It is also an important step in defining the mechanism of FMS, and this may lead to a change in classification from syndrome to disease.

Staud R.  2004.  Predictors of clinical pain intensity in patients with fibromyalgia syndrome.  Curr Rheumatol Rep. 6(4):281-286.  “The magnitude of wind-up after-sensations appeared to be one of the best predictors for clinical pain intensity of fibromyalgia syndrome patients (27%).”

Staud R. 2002.  Evidence of involvement of central neural mechanisms in generating fibromyalgia pain.  Curr Rheumatol Rep 4(4):299-305. "Fibromyalgia syndrome (FMS) is characterized by widespread pain, fatigue, sleep abnormalities, and distress.  Abnormal temporal summation of second pain (wind-up) and central sensitization have been described recently in patients with FMS.  Wind-up and central sensitization, which rely on activation of nocicepto-specific neurons and wide dynamic range neurons in the dorsal horn of the spinal cord.  Other abnormal central pain mechanisms recently detected in patients with FMS include diffuse noxious inhibitory controls.  These pain inhibitory mechanisms rely on spinal cord and supraspinal systems involving pain facilitatory and pain inhibitory pathways.  Brain-imaging techniques that can detect neuronal activation after nociceptive stimuli have provided additional evidence for abnormal central pain mechanism in FMS.  Brain images have corroborated the augmented reported pain experience of patients with fibromyalgia during experimental pain stimuli.  In addition, thalamic activity, which contributes significantly to pain processing, was decreased in fibromyalgia.  However, central pain mechanisms of fibromyalgia may not depend exclusively on neuronal activation.  Neuroglial activation has been found to play an important role in the induction and maintenance of chronic pain."

Staud R, Boissoneault J, Lai S, et al. 2021. Spinal cord neural activity of fibromyalgia patients and healthy controls during temporal summation of pain: An fMRI study. J Neurophysiol. 2021 Aug 18. Online ahead of print. "The cause for the increased sensitivity of fibromyalgia (FM) patients to painful stimuli is unclear but sensitization of dorsal horn spinal cord neurons has been suggested…. This study used repetitive stimuli that produce temporal-summation-of-second-pain (TSSP) and central sensitization, relevant mechanisms for patients with chronic pain…. During repetitive, sensitivity-adjusted heat stimuli, pain ratings of all subjects increased as predicted, consistent with TSSP."

Staud R, Cannon RC, Mauderli AP et al. 2003.  Temporal summation of pain from mechanical stimulation of muscle tissue in normal controls and subjects with fibromyalgia syndrome.  Pain 102(1-2):87-95.  “Temporal summation for FMS subjects occurred at substantially lower forces and at a lower frequency of stimulation.  Furthermore, painful after-sensations were greater in amplitude and more prolonged for FMS subjects.”  “Abnormal input from muscle nociceptors appears to underlie production of central sensitization in FMS that generalizes to input from cutaneous nociceptors,”

Staud R, Carpenter R, GodfreyM, et al. Hand size estimates of fibromyalgia patients are associated with clinical and experimental pain. PLoS One. 2022 Jul 25;17(7):e0270701. "Simply inspecting one's own body can reduce clinical pain and magnification of body parts can increase analgesia. Thus, body perceptions seem to play an important role for analgesia. Conversely, pain may also affect bodily perceptions. Therefore, we evaluated the effects of clinical and/or experimental pain on perceived hand size in fibromyalgia patients (FM) and healthy controls (HC)…. The decreased hand size perception of FM patients and HC was associated with their clinical and/or experimental pain, supporting the hypothesis that pain can result in visual body distortions."

Staud R, Godfrey MM, Riley JL, et al. Efficiency of pain inhibition and facilitation of fibromyalgia patients is not different from healthy controls: Relevance of sensitivity-adjusted test stimuli. Br J Pain. 2023 Apr;17(2):182-194. "Similar to previous studies, FM participants demonstrated hyperalgesia to heat, cold, and mechanical stimuli. However, using only sensitivity-adjusted stimuli during CPM (conditioned pain modulation) and temporal summation testing, FM patients demonstrated similarly effective pain inhibition and facilitation than HC, suggesting that their pain modulation is not abnormal."

Staud R, Godfrey MM, Robinson ME. 2021. Fibromyalgia patients are not only hypersensitive to painful stimuli but also to sound stimuli. J Pain. Feb 23. Online ahead of print. "FM patients are not only augmenting noxious sensations but also sound, suggesting that FM augmentation mechanisms are not only operant in the spinal cord but also in the brain. Whether the central nervous system mechanisms for auditory and nociceptive augmentation are similar, needs to be determined in future studies.... This study presents QST evidence that the hypersensitivity of FM patients is not limited to painful stimuli but also to innocuous stimuli like sound. Our results suggest that brain mechanisms may be responsible for the increased sensitivity of FM patients."

Staud R, Godfrey MM, Stroman PW. Fibromyalgia is associated with hypersensitivity but not with abnormal pain modulation: evidence from QST trials and spinal fMRI. Front Pain Res (Lausanne). 2023 Dec 5;4:1284103. Our recent investigations of pain modulation with individually adjusted nociceptive stimuli have confirmed the mechanical and thermal hyperalgesia of FM patients but failed to detect abnormalities of pain summation or descending pain inhibition. Furthermore, our functional magnetic resonance imaging evaluations of spinal and brainstem pain processing during application of sensitivity-adjusted heat stimuli demonstrated similar temporal patterns of spinal cord activation in FM and HC participants. However, detailed modeling of brainstem activation showed that BOLD (blood oxygenation level-dependent) activity during "pain summation" was increased in FM subjects, suggesting differences in brain stem modulation of nociceptive stimuli compared to HC. Whereas these differences in brain stem activation are likely related to the hypersensitivity of FM patients, the overall central pain modulation of FM showed no significant abnormalities. These findings suggest that FM patients are hyperalgesic but modulate nociceptive input as effectively as HC.

Staud R, Koo E, Robinson ME et al. 2007.  Spatial summation of mechanically evoked muscle pain and painful aftersensations in normal subjects and fibromyalgia patients.  Pain. [Apr 23 Epub ahead of print].  “…decreasing pain in some muscle areas by local anesthetics or other means may improve overall clinical pain of FM patients.”  [This is another indication that control of peripheral pain stimuli such as caused by myofascial trigger points and arthritis can be a significant part of chronic pain treatment in FM. DJS]

Staud R, Lucas YE, Price DD et al. 2015. Effects of milnacipran on clinical pain and hyperalgesia of patients with fibromyalgia: Results of a 6-week randomized controlled trial. J Pain.16(8):750-9. "Although clinical pain and hyperalgesia decreased during this 6-week trial, the efficacy of milnacipran was not superior to placebo. The high correlations between clinical pain and hyperalgesia ratings at every time point seem to emphasize the relevant contributions of mechanical and heat hyperalgesia to clinical FM pain."

Staud R, Nagel S, Robinson ME et al. 2009.  Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study.  Pain. [Jun 18 Epub ahead of print].  “Lidocaine injections increased local pain thresholds and decreased remote secondary heat hyperalgesia in FM patients, emphasizing the important role of peripheral impulse input in maintaining central sensitization in this chronic pain syndrome; similar to other persistent pain conditions such as irritable bowel syndrome and complex regional pain syndrome.” [This is yet another study showing that peripheral pain sensations such as those caused by myofascial TrPs are sufficient to maintain the central sensitization state of FM and may be important to maintaining other chronic conditions. DJS]

Staud R, Price DD, Robinson ME et al. 2004.  Body pain area and pain-related negative affect predict clinical pain intensity in patients with fibromyalgia.  J Pain 5(6):338-343.  “The number of painful body areas obtained by body pain diagrams is a better predictor of clinical pain intensity than TPS in FM patients.”  [It would be helpful if these patients were checked for co-existing myofascial TrPs.  It could be that the presence of co-existing myofascial TrPs is the better predictor of clinical pain intensity. DJS]

Staud R, Price DD, Robinson ME et al. 2004.  Body pain area and pain-related negative affect predict clinical pain intensity in patients with fibromyalgia. J Pain 5(6):338-343.  The combination of charts showing painful body areas, tender point counts, and pain-related negative emotions gave a much more accurate representation of pain intensity in FMS patients than did simple counting of tender points.

Staud R, Price DD, Robinson ME et al.  2004.  Maintenance of windup of second pain requires less frequent stimulation in fibromyalgia patients compared to normal controls.  Pain 110(3):689-696.  “Unlike NC (normal control) subjects, FM subjects showed enhanced second pain during WU-M (wind-up maintenance) stimuli at very low stimulus frequencies, indicating central sensitization.  Increased WU sensitivity, enhanced WU-M, and increased WU-related aftersensations help account for persistent pain conditions in FM subjects.”  [Patients with FMS may respond to lower stimuli to maintain a state of central sensitization.  Myofascial trigger points that would not cause central sensitization in healthy individuals may be sufficient to maintain central sensitization in patients with FMS. DJS]

Staud R, Robinson ME, Goldman CT et al. 2011. Attenuation of experimental pain by vibro-tactile stimulation in patients with chronic local or widespread musculoskeletal pain. Eur J Pain. [Feb 19 Epub ahead of print]. "One form of endogenous pain inhibition, diffuse noxious inhibitory controls (DNIC), has been found to be abnormal in some chronic pain patients and evidence exists for deficient spatial summation of pain, specifically in FM. Similar findings have been reported in patients with localized musculoskeletal pain (LMP) disorders, like neck and back pain. Whereas DNIC reduces pain through activation of nociceptive afferents, vibro-tactile pain inhibition involves innocuous A-beta fiber.....To assess endogenous analgesic mechanisms of study subjects, vibro-tactile conditioning stimuli were simultaneously applied with test stimuli either homotopically or heterotopically. Additionally, the effect of distraction on experimental pain was assessed. Homotopic vibro-tactile stimulation resulted in 40% heat pain reductions in all subject groups.....Conclusions: Vibro-tactile stimulation effectively recruited analgesic mechanisms not only in NC (normal pain-free controls) but also in patients with chronic musculoskeletal pain, including FM. Distraction did not seem to contribute to this analgesic effect."

Staud R, Robinson ME, Price DD. 2007.  Temporal summation of second pain and its maintenance are useful for characterizing widespread central sensitization of fibromyalgia patients.  J Pain. [Aug 1 Epub ahead of print].  “Perspective:  The pain of FM seems to be accompanied by generalized central sensitization, involving the length of the spinal neuroaxis.  Thus, widespread central sensitization appears to be a hallmark of FM and may be useful for the clinical case definition of this prevalent pain syndrome.  In addition, measures of widespread central sensitization, like TSSP-M (temporal summation of second pain and maintenance), could also be used to assess treatment responses of FM patients.”

Staud R, Robinson ME, Weyl EE et al. 2010. Pain variability in fibromyalgia is related to activity and rest: role of peripheral tissue impulse input. J Pain. [May 6 Epub ahead of print]. “FM is a pain-amplification syndrome that depends at least in part on peripheral tissue impulse input. Whereas muscle activity increased overall pain, short rest periods produced analgesic effects.” [This indicates that in cases of FM, short rest periods may enable us to accomplish some activities. This agrees with Travell and Simons’ recommendations for myofascial trigger points, which often cause the peripheral pain stimuli maintaining FM central sensitization. We must remember to rest every 20 minutes, or whatever our time limit is for each task. DJS] 

Staud R, Smitherman ML. 2002.  Peripheral and central sensitization in fibromyalgia: pathogenetic role. Curr Pain Headache Rep 6(4):259-66. "Patients with fibromyalgia show psychophysical evidence of mechanical, thermal and electrical hyperalgesia. Peripheral and central abnormalities of nociception have been described in fibromyalgia. Important nociceptor systems in the skin and muscles seem to undergo profound changes..."  "These include sensitization of vanilloid receptor, acid-sensing ion channel receptors, and purino-receptors. Tissue mediators of inflammation and nerve growth channel receptors can excite these receptors and cause extensive change in pain sensitivity, but patients with fibromyalgia lack consistent evidence for inflammatory soft tissue abnormalities."

Staud R, Vierck CJ, Robinson ME et al. 2006.  Overall fibromyalgia pain is predicted by ratings of local pain and pain-related negative affect – possible role of peripheral tissues.  Rheumatology (Oxford) [Apr 18 Epub ahead of print]  “We hypothesized that the overall clinical pain is largely determined by the pain intensity of local body areas.  Thus, we assessed the role of local body pains as predictors of overall clinical pain in FM patients.”  “Peripheral factors (maximal/average local pain and number of painful body areas) predicted most of the variance of overall clinical FM pain, suggesting that the input of pain by the peripheral tissues is clinically relevant.  About 19% of the pain variance was predicted by PRNA.  Thus, peripheral pain and negative affect appear to be particularly relevant for overall FM pain and may represent important targets for future therapies.”

Staud R, Vierck CJ, Robinson ME et al. 2005.  Effects of the N-Methyl-D-Aspartate receptor antagonist Dextromethorphan on temporal summation of pain are similar in fibromyalgia patients and normal control subjects.  Jour Pain 6(5):323-332.

Staud R, Weyl EE, Bartley E et al. 2013. Analgesic and anti-hyperalgesic effects of muscle injections with lidocaine or saline in patients with fibromyalgia syndrome. Eur J Pain. [Nov 5 Epub ahead of print.] This double-blind controlled study of 62 women with fibromyalgia utilized injection into trapezius and gluteal trigger points with either saline or lidocaine. The results indicate that injection of peripheral trigger point pain generators can reliably and significantly reduce clinical fibromyalgia pain. This research strongly suggests that, at least in women, it is the input from peripheral pain generators such as trigger points that maintain the mechanical and heat hyperalgesia of fibromyalgia. "…effects of muscle injections on hyperalgesia were greater for lidocaine than saline; the effects on clinical pain were similar for both injectates."

Staud R, Weyl EE, Price DD et al. 2012. Mechanical and Heat Hyperalgesia Highly Predict Clinical Pain Intensity in Patients with Chronic Musculoskeletal Pain Syndromes. J Pain. [Jun 26 Epub ahead of print]. "Multiple abnormalities in pain processing have been reported in patients with chronic musculoskeletal pain syndromes. These changes include mechanical and thermal hyperalgesia, decreased thresholds to mechanical and thermal stimuli (allodynia), and central sensitization, all of which are fundamental to the generation of clinical pain.....we hypothesized that quantitative sensory tests may provide useful predictors of clinical pain intensity of such patients..... Using either heat or pressure pain ratings as well as tender point counts and negative affect as predictors, up to 49.4% of the patients' variance of clinical pain intensity could be estimated....Simple tests of mechanical and heat hyperalgesia can predict large proportions of the variance in clinical pain intensity of chronic musculoskeletal pain patients and thus are feasible to be included in clinical practice and clinical trials."

Staud R, Weyl EE, Riley JL 3rd et al. 2014. Slow temporal summation of pain for assessment of central pain sensitivity and clinical pain of fibromyalgia patients. PLoS One. 9(2):e89086. "In healthy individuals slow temporal summation of pain or wind-up (WU) can be evoked by repetitive heat-pulses at frequencies of ≥ .33 Hz. Previous WU studies have used various stimulus frequencies and intensities to characterize central sensitization of human subjects including fibromyalgia (FM) patients. However, many trials demonstrated considerable WU-variability including zero WU or even wind-down (WD) at stimulus intensities sufficient for activating C-nociceptors. Additionally, few WU-protocols have controlled for contributions of individual pain sensitivity to WU-magnitude, which is critical for WU-comparisons. ….Slope of WU-RF, which is representative of central pain sensitivity, was significantly steeper in FM patients than NC (normal controls) ....Compared to single WU series, WU-RFs integrate individuals' pain sensitivity as well as WU and WD. Slope of WU-RFs was significantly different between FM patients and NC. Therefore WU-RF may be useful for assessing central sensitization of chronic pain patients in research and clinical practice." Free PMC Article

Stecco A, Cowman M, Pirri N, Preeti Raghavan et al. 2022. Densification: Hyaluronan aggregation in different human organs. Bioengineering (Basel). Apr 5;9(4):159. "Hyaluronan (HA) has complex biological roles that have catalyzed clinical interest in several fields of medicine. In this narrative review, we provide an overview of HA aggregation, also called densification, in human organs. The literature suggests that HA aggregation can occur in the liver, eye, lung, kidney, blood vessel, muscle, fascia, skin, pancreatic cancer and malignant melanoma. In all these organs, aggregation of HA leads to an increase in extracellular matrix viscosity, causing stiffness and organ dysfunction. Fibrosis, in some of these organs, may also occur as a direct consequence of densification in the long term. Specific imaging evaluation, such dynamic ultrasonography, elasto-sonography, elasto-MRI and T1? MRI can permit early diagnosis to enable the clinician to organize the treatment plan and avoid further progression of the pathology and dysfunction." [This research may have profound implications in many fields of medicine. It is to be hoped that clinicians recognize this and keep alert to further developments. DJS]

Stecco A, Gesi M, Stecco C et al. 2013. Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep. 17(8):352. "Myofascial pain syndrome (MPS) is described as the muscle, sensory, motor, and autonomic nervous system symptoms caused by stimulation of myofascial trigger points (MTP). The participation of fascia in this syndrome has often been neglected. Several manual and physical approaches have been proposed to improve myofascial function after traumatic injuries, but the processes that induce pathological modifications of myofascial tissue after trauma remain unclear. Alterations in collagen fiber composition, in fibroblasts or in extracellular matrix composition have been postulated. We summarize here recent developments in the biology of fascia, and in particular, its associated hyaluronan (HA)-rich matrix that address the issue of MPS."

Stecco A, Meneghinie A, Stern R et al. 2014. Ultrasonography in myofascial neck pain: randomized clinical trial for diagnosis and follow-up. Surg Radiol Anat. 36(3):243-253. "This study compared active and passive cervical range of motion, along with a neck disability questionnaire. "The fascial thickness of the sternal ending of the sternocleidomastoid and medial scalene muscles was also analyzed by ultrasonography. …. There were significant differences between healthy subjects and patients with CNP in the thickness of the upper side of the sternocleidomastoid fascia and the lower and upper sides of the right scalene fascia both at the end of treatment as during follow-up." There was a significant difference in pain, as well as the amount of loose connective tissue after treatment. "The variation of thickness of the fascia correlated with the increase in quantity of the loose connective tissue but not of dense connective tissue."

Stecco A, Stecco C, Macchi V et al. 2011. RMI study and clinical correlations of ankle retinacula damage and outcomes of ankle sprain. Surg Radiol Anat. [Feb 9 Epub ahead of print]. Alterations shown by MRI in ankle retinacula from trauma or chronic ankle instability corresponds to proprioceptive damage noted by photography and clinical exam. This indicates that the ankle reticulinum are not passive stabilizers but also involved in proprioceptive function. Deep massage of the ankle retinacula alleviated these symptoms. The authors state that adaptive fibrosis may develop as a consequence of unremitting non-physiological tension in a fascial segment. The deep friction massage changes the nature of the ground substance, restoring glide. They believe this to be due to changes in the myofascia rather than to bones or ligaments. [Correspondence with the authors revealed that they also have found trigger points in retinacula. DJS]

Stecco C, Fede C, Macchi V et al. 2018. The fasciacytes: A new cell devoted to fascial gliding regulation. Clin Anat. [Mar 25 Epub ahead of print] Hyaluronic acid, also called hyaluronan, is a substance that occurs between the deep fascia and the muscles, and also within loose fascial connective tissue. Hyaluronan facilitates the sliding of the tissues during movement. This study found a new class of fascial cells, called fascicytes; cells similar to fibroblasts. Fascicytes produce substances of the extracellular matrix, an area high in hyaluronan. "The authors suggest that these cells represent a new cell type devoted to the production of hyaluronan. Since hyaluronan is essential for fascial gliding, regulation of these cells could affect the functions of fasciae so they could be implicated in myofascial pain."

Stecco C, Gagey O, Belloni A et al. 2007. Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie 91(292):38-43. This study indicates that the flexor retinaculum has more proprioceptive functions, whereas the tendons were primarily mechanical in function. "…the fascia is a membrane that extends throughout the whole body and numerous muscular expansions maintain it in a basal tension. During a muscular contraction these expansions could also transmit the effect of the stretch to a specific area of the fascia, stimulating the proprioceptors in that area."

Stecco C, Macchi V, Porzionato A et al. 2010. The ankle retinacula: morphological evidence of the proprioceptive role of the fascial system. Cells Tissues Organs 192(3):200-210. "The retinacula are not static structures for joint stabilization, like the ligaments, but a specialization of the fascia for local spatial proprioception of the movements of the foot and ankle. Their anatomical variations and accessory bundles may be viewed as morphological evidence of the integrative role of the fascial system in peripheral control of articular motility."

Stecco C, Stern R, Prozionato A et al. 2011. Hyaluronan within fascia in the etiology of myofascial pain. Surg Radiol Anat 33(10):891-896. This study focused on hyaluronic acid in the fascial layers. "The HA within the deep fascia facilitates the free sliding of two adjacent fibrous fascial layers, thus promoting the normal function associated with the deep fascia. If the HA assumes a more packed confirmation, or more generally, if the loose connective tissue inside the fascia alters its density, the behavior of the entire deep fascia and the underlying muscle would be compromised, This, we predict, may be the basis of the common phenomenon known as "myofascial pain." This study describes the fascial reservoir as a "…reservoir of water and ions for surrounding tissues. It may also function as a reservoir to accumulate and remove various degradation products and toxic substances…A fundamental element of the loose connective tissue (ground substance) is the HA, and its concentration determines, together with the temperature and other physical parameters, the density of the matrix. " The study proposes the mechanism of increasing viscosity of ground substance, and proposes a new type of cell they call the "fasciacyte." [This study confirms increased hyaluronic acid in myofascial pain areas (what we found in the geloid mass over areas of resistant TrPs), and gives new anatomical fascial insights and a new direction in what may be a promising way to relieve and even reverse myofascial pain. DJS]

Steen Pettersen P, Neogi T, Magnusson K et al. 2019. Peripheral and central sensitization of pain in individuals with hand osteoarthritis and associations with self-reported pain severity. Arthritis Rheumatol. [Feb 11 Epub ahead of print] "Pain sensitization, an important osteoarthritis (OA) pain mechanism, has not been substantially investigated in persons with hand OA….Central sensitization was common in persons with hand OA…. Sensitization may therefore represent a possible treatment target." [Any chronic peripheral pain generator may be maintaining the central sensitization. DJS]

Steinberg N, Tenenbaum S, Zeev A, et al. 2021. Generalized joint hypermobility, scoliosis, patellofemoral pain, and physical abilities in young dancers. BMC Musculoskelet Disord. Feb 9;22(1):161. "A high prevalence of young girls participating in dance classes had GJH (generalized joint hypermobility), as the increased joint flexibility probably provides them with some esthetic advantages. The high prevalence of scoliosis found in these young dancers might be attributed to their relatively low body mass, their delayed maturation, and the selection process of dancers. Dancers with both GJH and scoliosis had decreased muscle strength, reduced postural balance, reduced proprioception, with higher risk of PFP."

Stejskal V, Ockert K, Bjørklund G. 2013. Metal-induced inflammation triggers fibromyalgia in metal-allergic patients. Neuro Endocrinol Lett. 34(6):559-565. "Fifteen female FM patients were included in the study. Metal allergy was measured by a lymphocyte transformation test, MELISA®….All FM patients tested positive to at least one of the metals tested. The most frequent reactions were to nickel, followed by inorganic mercury, cadmium and lead. Some healthy controls responded to inorganic mercury in vitro but most of the tests were negative. Objective examination 5 years later showed that half of the patients no longer fulfilled the FM diagnosis, 20% had improved and the remaining 30% still had FM. All patients reported subjective health improvement."

Sterling M, Jull G, Vicenzino B et al. 2003.  Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery.  Pain 104(3):509-517.  “These findings suggest that those with persistent moderate/severe symptoms at six months display, soon after injury, generalized hypersensitivity suggestive of changes in central pain processing mechanisms.  This phenomenon did not occur in those who recover or those with persistent mild symptoms.”
 

Sterling M, Jull G, Vicenzino B et al. 2003.  Development of motor system dysfunction following whiplash injury.  Pain 103(1-2):65-73.  “This study identifies, for the first time, deficits in the motor system, as early as one month post whiplash injury, that persisted not only in those reporting moderate/severe symptoms at three months but also in subjects who recovered and those with persistent mild symptoms.”

Sterling M, Kenardy J, Jull G et al. 2003.  The development of psychological changes following whiplash injury.  Pain 106(3):481-489.  “This study identifies, for the first time, deficits in the motor system, as early as 1 month post whiplash injury, that persisted not only in those reporting moderate/severe symptoms at 3 months but also in subjects who recovered and those with persistent mild symptoms.”

Sterling M., Treleven J., Edwards S. et al. 2002.  Pressure pain thresholds in chronic Whiplash Associated Disorder: further evidence of altered central pain processing. Central sensitization may occur after whiplash.  J Musculoskel Pain 10(3):69-81.

Sterling M, Jull G, Wright A. 2001. The effect of musculoskeletal pain on motor activity and control. [No journal listed] 2(3):135-145. Patterns of muscle activation and recruitment are altered in the presence of pain.  "These changes seem to particularly affect the ability of muscles to perform synergistic functions related to maintaining joint stability and control.  It is apparent that people experiencing musculoskeletal pain exhibit complex motor responses that may show some variation with the time course of the disorder."

Stewart, D. P., J. Kaylor and E. Koutanis. 1996. Cognitive deficits in presumed minor head injured patients. Acad Emerg Med 3 (1):21-26.

Stewart WF, Ricci JA, Chee E et al. 2003.  Lost productive time and cost due to common pain conditions in the US workforce. JAMA 290(18):2443-2454.  Pain is not only a common disability keeping people from the workforce, but AMost of the pain-related lost productive time occurs while employees are at work and is in the form of reduced performance.@

Stoicea N, Russell D, Weidner G et al. 2015. Opioid-induced hyperalgesia in chronic pain patients and the mitigating effects of gabapentin. Front Pharmacol. 6:104. eCollection. "Chronic pain patients receiving opioid drugs are at risk for opioid-induced hyperalgesia (OIH), wherein opioid pain medication leads to a paradoxical pain state. OIH involves central sensitization of primary and secondary afferent neurons in the dorsal horn and dorsal root ganglion, similar to neuropathic pain. Gabapentin, a gamma-aminobutyric acid (GABA) analog anticonvulsant used to treat neuropathic pain, has been shown in animal models to reduce fentanyl hyperalgesia without compromising analgesic effect. Chronic pain patients have also exhibited lower opioid consumption and improved pain response when given gabapentin. However, few human studies investigating gabapentin use in OIH have been performed in recent years. In this review, we discuss the potential mechanisms that underlie OIH and provide a critical overview of interventional therapeutic strategies, especially the clinically-successful drug gabapentin, which may reduce OIH." Free PMC Article

Storari M, Zerman N, Salis B et al. Chronic facial pain in fibromyalgia: May electromagnetic field represent a promising new therapy? A pilot randomized-controlled study. Int J Environ Res Public Health. 2022 Dec 26;20(1):391. "Significant differences were found between patients who received placebo and those treated. Treated patients showed statistically significant improvements in facial/cervical pain at each time-point, both with respect to the previous one and if compared to placebo. In conclusion, low frequency electromagnetic field emerged as beneficial in treating cervico-facial pain in patients with Fibromyalgic syndrome, with no side effects."

Stormorken H, Brosstad F. 2005.  [Frequent urination—an important diagnostic marker in fibromyalgia]  Tidsskr Nor Laegeforen 125(1):17-19. [Norwegian]  “An abnormally high frequency of urination is a characteristic feature in fibromyalgia and a useful diagnostic variable.  The pattern is that of urge, sometimes with incontinence.”  [This study would have been more useful had the patients been screened for co-existing myofascial TrPs that can cause the same symptoms and yet can respond immediately to appropriate treatment. DJS.]

Stranden M, Solvin H, Fors EA et al. 2016. Are persons with fibromyalgia or other musculoskeletal pain more likely to report hearing loss? A HUNT study. BMC Musculoskelet Disord. 17(1):477. "In adjusted analysis, individuals with fibromyalgia had increased likelihood to report subjective hearing loss, compared to persons without fibromyalgia or other musculoskeletal pain...in women and men". Furthermore, people with local and widespread musculoskeletal pain not diagnosed with fibromyalgia, also had increased likelihood to report subjective hearing loss, compared to people with no musculoskeletal pain. This relationship was greater for widespread pain than for localized pain... in women and men with local musculoskeletal pain and… in women and men with widespread pain, respectively…. Our findings are consistent with the hypothesis that fibromyalgia is related to a general dysregulation of the central nervous system. The same might also be the case for other local and, in particular, other widespread, musculoskeletal pain. Free PMC Article

Stratton P, Khachikyan I, Sinaii N et al. 2015. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstet Gynecol. 125(3):719-728. "Sensitization and myofascial trigger points were common in women with pain regardless of whether they had endometriosis at surgery. Those with any history of endometriosis were most likely to have sensitization. Traditional methods of classifying endometriosis-associated pain based on disease, duration, and anatomy are inadequate and should be replaced by a mechanism-based evaluation, as our study illustrates."

Streit RS. 2014. NTOS symptoms and mobility: A case study on neurogenic thoracic outlet syndrome involving massage therapy. J Bodyw Mov Ther. 18:42-48. "Neurogenic thoracic outlet syndrome (NTOS) is a neuromuscular condition affecting brachial plexus functionality. NTOS is characterized by paresthesia, pain muscle fatigue, and restricted mobility in the upper extremity. This study quantified massage therapy's possible contribution to treatment of NTOS. A 24-year-old female with NTOS received eight treatments over 35 days. Treatment included myofascial release, trigger point therapy, cross fiber friction, muscle stripping, and gentle passive stretching. Abduction and lateral rotation at the glenohumeral (GH joint) assessments measured range of motion (ROM). A resisted muscle test evaluated upper extremity strength. The client rated symptoms daily via a visual analog scale (VAS). Findings showed improvement in ROM at the GH joint. VAS ratings revealed a reduction in muscle weakness, pain, numbness, and 'paresthesia'. Results suggest massage may be useful as part of a broad approach to managing NTOS symptoms and improving mobility."

Strickler EM, Schwenk ES, Cohen MJ et al. 2017. Use of ketamine in a multimodal analgesia setting for rapid opioid tapering in a profoundly opioid-tolerant patient: A case report. A A Case Rep. [Oct 17 Epub ahead of print] "Opioids are frequently used for the treatment of chronic pain, and patients taking high doses are at increased risk of complications and adverse opioid-related events. Ketamine is appealing as an opioid adjunct because of its lack of respiratory depression and potential prevention of hyperalgesia and central sensitization. We present a case in which a ketamine infusion was utilized over a 7-day period to provide rapid taper of a daily dose of 400 mg of morphine equivalents to less than one-third of that dose on discharge with unchanged pain levels and no symptoms of opioid withdrawal."

Strimpakos N. 2011. The assessment of the cervical spine. Part 1: Range of motion and proprioception. J Bodyw Mov Ther. 15(1):114-124. "Neck pain and headache of cervical origin are complaints affecting an increasing number of the general population. Mechanical factors such as sustained neck postures or movements and long-term "abnormal" physiologic loads on the neck are believed to affect the cervical structures and compromise neck function. A comprehensive assessment of neck function requires evaluation of its physical parameters such as range of motion, proprioception, strength and endurance/fatigue. The complicated structure of the cervical spine however, makes it difficult for any clinician to obtain reliable and valid results. The aim of the first part of this systematic critical review is to identify the factors influencing the assessment of range of motion and proprioception of the cervical spine."

Strom V, Røe C, Matre D et al. 2017. Deep tissue hyperalgesia after computer work. Scand J Pain. 3(1):53-60. "A decrease in pressure pain thresholds of involved muscles suggests that computer office-work can induce deep tissue hyperalgesia within 90 min. The development of pain during the computer work indicates peripheral sensitization as the predominant mechanism. Decreased pressure pain thresholds also in sites distant from pain areas may indicate a contribution from central sensitization in the subjects with chronic shoulder and neck pain. Implications The lasting pain after work and the reduced PPTs both in involved and distant musculature may indicate need for frequent pauses during computer work, especially when performed with time pressure and high precision demands, in order to avoid pain to increase and sustain after work, and thus to prevent the possibility of pain to become chronic."

Stryła W, Pogorzała AM, Stępień J. 2013. Proprioception exercises in medical rehabilitation. Pol Orthop Traumatol. 78:5-27. "Proprioception, or kinesthesia, is the sense of orientation responsible for perception of body and relative position of its parts. Kinesthesia is received by receptors located in muscles and tendons. In this study a set of proprioception developing exercises was presented. Proprioception should be restored in case of musculoskeletal and neurological disorders. Proprioception training can also be used as a prophylaxis before starting various sporting activities. Proprioception developing exercises have significant meaning for the elderly, who are at risk of balance disorders. These exercises help developing motor memory and at the same time protect from falls." [All care providers must understand that myofascial TrPs can have associated proprioceptive and/or autonomic dysfunction. DJS]

Stuifbergen AK, Phillips L, Carter P et al. 2010. Subjective and objective sleep difficulties in women with fibromyalgia syndrome. J Am Acad Nurse Pract. 22(10):548-556. "Sleep problems are a major concern among women with FMS. Those with concurrent depressive symptoms, high pain, and limited functioning may be candidates for in-depth sleep assessment and behavioral programs to improve sleep." [When pain is a major cause of sleep impairment, the causes of pain must be addressed. Co-existing sleep dysfunctions, such as obstructive sleep apnea, must also be addressed. Myofascial trigger points may be major components of these. Often, the psychological support is needed to address the failure of medicine to promptly and adequately address the causes of pain and dysfunction and support the patients with these conditions. DJS]

Stussman BJ, Nahin RL, Ceko M3. 2018. Fibromyalgia patients and healthy volunteers express difficulties and variability in rating experimental pain: a qualitative study. Scand J Pain. [Aug 11 Epub ahead of print] "Three notable differences were found between fibromyalgia patients and healthy volunteers: (1) using current daily pain as a benchmark was seen more in patients, (2) wanting to appear strong in front of the study investigators was more common in healthy volunteers, and (3) becoming mentally fatigued from rating many stimuli was more common for fibromyalgia patients. Thoughts while scoring pain included: (1) comparing with previous or current pain, (2) self-monitoring of one's ability to endure the pain, (3) focusing on the physical aspects of the pain, (4) knowing the experimental setting is safe, (5) focusing on the pain scale as an anchor, and (6) desire to appear strong. Additionally, five difficulties in scoring experimental pain were identified: (1) falling asleep, (2) mentally fatigued, (3) feeling as though they were guessing, (4) having to make a quick decision, and (5) difficulty in being consistent.... Participants were distracted and influenced by the experimental setting and some factors differed for fibromyalgia patients versus healthy volunteers.... Understanding the ways in which the experimental setting influences pain ratings may help pain researchers better design and interpret studies. Researchers can use these findings to mitigate difficulties for participants in experimental research to add to its validity."

Su PYP, Zhang L, He L, et al. The Role of Neuro-Immune Interactions in Chronic Pain: Implications for Clinical Practice. J Pain Res. 2022 Aug 4;15:2223-2248. "Chronic pain remains a public health problem and contributes to the ongoing opioid epidemic. Current pain management therapies still leave many patients with poorly controlled pain, thus new or improved treatments are desperately needed. One major challenge in pain research is the translation of preclinical findings into effective clinical practice. The local neuroimmune interface plays an important role in the initiation and maintenance of chronic pain and is therefore a promising target for novel therapeutic development. Neurons interface with immune and immunocompetent cells in many distinct microenvironments along the nociceptive circuitry. The local neuroimmune interface can modulate the activity and property of the neurons to affect peripheral and central sensitization. In this review, we highlight a specific subset of many neuroimmune interfaces. In the central nervous system, we examine the interface between neurons and microglia, astrocytes, and T lymphocytes. In the periphery, we profile the interface between neurons in the dorsal root ganglion with T lymphocytes, satellite glial cells, and macrophages. To bridge the gap between preclinical research and clinical practice, we review the preclinical studies of each neuroimmune interface, discuss current clinical treatments in pain medicine that may exert its action at the neuroimmune interface, and highlight opportunities for future clinical research efforts." [This review offers clues to the interactivity of many co-existing illnesses. For example, patients with FM central sensitization frequently have an abundance of pain sources, which FM then amplifies. Their TrPs are often undiagnosed, as may be hypothyroidism, insulin resistance, and other coexisting conditions. Far too often, doctors are content with labelling patients with FM and then throwing pills their way, when many times their pain sources, and the perpetuating factors of same, can be treated. Bringing attention to the underlying immune connections is a great service. I have asked neuro researchers why they are not focusing on glial cells. They say the neurons are where the money is. I hope that the people who fund research will read this review. DJS]

Sucher BM. 1995.  Palpatory diagnosis and manipulative management of carpal tunnel syndrome: Part 2. ‘Double crush’ and thoracic outlet syndrome.  J Am Osteopath Assoc. 95(8):471-479.  “The physician treating carpal tunnel syndrome needs to be aware of the possible concomitant occurrence of thoracic outlet syndrome, the so-called double crush syndrome.  Palpation is used to differentiate carpal tunnel syndrome from thoracic outlet syndrome.  Such palpatory examination assists the physician in planning the initial treatment, including osteopathic manipulation and self-stretching maneuvers, targeted specifically at the most clinically significant pathologic region.  Supplemental physical medicine modalities such as ultrasound may enhance the treatment response. Some illustrative cases are reported.”  [Carpal tunnel syndrome often co-exists with TOS.   Myofascial trigger points can cause symptoms of both, so the examining clinician needs to look for patterns, and for TrPs.  DJS]

Sucher, B. M. 1993. Myofascial release of carpal tunnel syndrome. J Am Osteopath Assoc 93(1):92-94.

Sugawa T, Fujiwara Y, Okuyama M et al. 2007.  [Prevalence, diagnosis and treatment of extraesophageal manifestation of GERD] Nippon Rinsho. 65(5):946-950. [Japanese]   “Gastroesophageal reflux disease (GERD) is associated with a variety of extraesophageal symptoms including asthma, chronic cough, laryngeal disorders, and various ENT symptoms.  Recent studies suggest that GERD underlies or contributes to chronic sinusitis, chronic otitis media, dental erosion and obstructive sleep apnea syndrome (OSAS).”

Suh MR, Chang WH, Choi HS et al. 2014. Ultrasound-guided myofascial trigger point injection into brachialis muscle for rotator cuff disease patients with upper arm pain: a pilot study. Ann Rehabil Med. 38(5):673-681. This study from South Korea found that: "In patients with rotator cuff disease, US-guided trigger point injection of the brachialis muscle is safe and effective for both diagnosis and treatment when the cause of pain is suspected to be originated from the muscle." Free PMC Article

Suhnan AP, Finch PM, Drummond PD. 2017. Hyperacusis in chronic pain: neural interactions between the auditory and nociceptive systems. Int J Audiol. 7:1-9. "Sensory disturbances are common in chronic pain patients. Hyperacusis can be an especially debilitating experience. Here, we review published work on how the auditory and nociceptive systems might interact in chronic pain syndromes to produce pain-hyperacusis…. Hyperacusis is a significant but under-recognised symptom in conditions such as complex regional pain syndrome and fibromyalgia, and an integral feature of migraine…. Nociceptive circuits become hypersensitive in acute and chronic pain; this sensitivity spreads from the periphery to spinal neurons and higher centres in the brain, leading to hyperalgesia or spontaneous pain even in the absence of peripheral nociceptive input.." [Hypersensitive hearing can have both an FM and TrP component. DJS]

Suleiman S, Johnston DE. 2001.  The abdominal wall: an overlooked source of pain.  Am Fam Physician 64(3):431-438.  “When abdominal pain is chronic and unremitting, with minimal or no relationship to eating or bowel function but often a relationship to posture (i.e., lying, sitting, standing), the abdominal wall should be suspected as the source of pain.  Frequently, a localized, tender trigger point can be identified, although the pain may radiate over a diffuse area of the abdomen.  If tenderness is unchanged or increased when abdominal muscles are tensed (positive Carnett’s sign), the abdominal wall is the likely origin of pain.  Most commonly, abdominal wall pain is related to cutaneous nerve root irritation or myofascial irritation.  The pain can also result from structural conditions, such as localized endometriosis or rectus sheath hematoma, or from incisional or other abdominal wall hernias.  If hernia or structural disease is excluded, injection of a local anesthetic with or without a corticosteroid into the pain trigger point can be diagnostic and therapeutic.”

Sullere S, Kunczt A, McGehee DS. A cholinergic circuit that relieves pain despite opioid tolerance. Neuron. 2023 Sep 12:S0896-6273(23)00627-X. In vivo 2-photon imaging revealed that chronic pain induces aberrant excitability of vlPAG neuronal ensembles and that α7 nAChR-mediated inhibition of these cells relieves pain, even after opioid tolerance. Finally, pain relief through these cholinergic mechanisms was not associated with tolerance, reward, or withdrawal symptoms, highlighting its potential clinical relevance.… The descending pain-modulatory pathway is an evolutionarily conserved neural circuit that encodes and modulates nociceptive signaling based on internal states and external stimuli.

Sullivan MD, Cahana A, Derbyshire S et al. 2013. What does it mean to call chronic pain a brain disease? J Pain. 14(4):317-322. "When considering the significance of neuroimaging results, it is important to remember that "disease" is a concept that arises out of clinical medicine, not laboratory science. Following Canguilhem, we believe that disease is best defined as a structural or functional change that causes disvalue to the whole organism. It is important to be cautious in our assertions about chronic pain as a brain disease because these may have negative effects on 1) the therapeutic dialogue between clinicians and patients; 2) the social dialogue about reimbursement for pain treatments and disability due to pain; and 3) the chronic pain research agenda.... We should not see pain caused by the brain alone. Pain is not felt by the brain, but by the person….conceiving of chronic pain as a brain disease can have negative consequences for research and clinical care of patients with chronic pain."

Sumelahti ML, Mattila K, Sumanen M. 2018. Painful musculoskeletal disorders and depression among working aged migraineurs. Acta Neurol Scand. [Mar 14 Epub ahead of print] "Recognition of comorbid musculoskeletal disorders and mood disorders among migraineurs needs targeted outreach in working aged population. The acute and preventive treatments to control for neuronal sensitization in migraine and comorbid pain disorders may benefit of individual treatment plan and tailored use of antidepressants."

Sumen A, Sarsan A, Alkan H et al. 2014. Efficacy of low level laser therapy and ?ntramuscular electrical stimulation on myofascial pain syndrome. J Back Musculoskelet Rehabil. [Jul 24 Epub ahead of print.] "Myofascial pain syndrome (MPS) which is an important cause of musculoskeletal pain has shown a dramatic increase in recent years….An improvement was found in all parameters for all groups, except for the pain threshold within the control group at the end of the treatment and one month after the treatment. It was found that pain score was significantly lower in Group 1 and 2 at one month after the treatment compared to Group 3. Similarly, it was found that pain threshold score was significantly higher in Group 2 at one month after the treatment compared to Group 3….In this study we observed that both LLLT and IMS treatments added on to stretching are effective in improving pain parameters in patients with MPS."

Sun A, Yeo HG, Kim TU et al. 2014. Radiologic assessment of forward head posture and its relation to myofascial pain syndrome. Ann Rehabil Med. 38(6):821-826. "Forward head posture and reduced cervical lordosis were seen more in younger patients with spontaneous neck pain. However, these abnormalities did not correlate with the location or the number of MPS. Further studies are needed to delineate the mechanism of neck pain in patients with forward head posture." Free PMC Article

Sun BL, Wang LH, Yang T et al. 2017. Lymphatic drainage system of the brain: A novel target for intervention of neurological diseases. Prog Neurobiol. [Sep 10 Epub ahead of print] "The belief that the vertebrate brain functions normally without classical lymphatic drainage vessels has been held for many decades. On the contrary, new findings show that functional lymphatic drainage does exist in the brain..... Brain lymphatic drainage helps maintain water and ion balance of the ISF, waste clearance, and reabsorption of macromolecular solutes. A second physiological function includes communication with the immune system modulating immune surveillance and responses of the brain. These physiological functions are influenced by aging, genetic phenotypes, sleep-wake cycle, and body posture. The impairment and dysfunction of the brain lymphatic system has crucial roles in age-related changes of brain function and the pathogenesis of neurovascular, neurodegenerative, and neuroinflammatory diseases, as well as brain injury and tumors. In this review, we summarize the key component elements (regions, cells, and water transporters) of the brain lymphatic system and their regulators as potential therapeutic targets in the treatment of neurologic diseases and their resulting complications. Finally, we highlight the clinical importance of ependymal route-based targeted gene therapy and intranasal drug administration in the brain by taking advantage of the unique role played by brain lymphatic pathways in the regulation of CSF flow and ISF/CSF exchange."

Sun WQ, Zhou AG, Pan DB et al.2020. Myofascial trigger point dry needling for complex regional pain syndrome: a case report. Acupunct Med. 2020 Nov 30 Online ahead of print. Dry needling of myofascial trigger points can moderate symptoms. [Researchers are looking at co-existing TrPs that may be adding to the symptom burden in chronic pain conditions. I have observed that myofascial pain and dysfunction may be a risk factor for development (and progression of) CRPS. DJS]

Sundermann B, Dehghan Nayyeri M, Pfleiderer B et al. 2019. Subtle changes of gray matter volume in fibromyalgia reflect chronic musculoskeletal pain rather than disease-specific effects. Eur J Neurosci. [Aug 26 Epub ahead of print] "Since no differences between both pain groups (fibromyalgia and osteoarthritis) could be detected cortical GMV (gray matter volume) changes in FMS should not be interpreted as FMS-specific but might rather reflect changes in chronic pain in general. This previously held notion is confirmed in this study by direct comparison with a control group consisting of another pain disorder."

Sung YH. Suboccipital muscles, forward head posture, and cervicogenic dizziness. Medicina (Kaunas). 2022 Dec 5;58(12):1791. Dizziness or vertigo can be caused by dysfunction of the vestibular or non-vestibular systems…. Among head and neck muscles, suboccipital muscles act as stabilizers and controllers of the head. Structural and functional changes of the suboccipital muscles can induce dizziness. Especially, myodural bridges and activation of trigger point stimulated by abnormal head posture may be associated with cervicogenic dizziness.

Surian AA, Baraniuk JN. 2020. Systemic hyperalgesia in females with Gulf War Illness, chronic fatigue syndrome and fibromyalgia. Sci Rep. 10(1):5751. "Pain is a diagnostic criterion for Gulf War Illness (GWI), chronic fatigue syndrome (CFS), and fibromyalgia (FM). Pressure was applied by dolorimetry at 18 traditional tender points and the average pressure causing pain determined. GWI women were the most tender…followed by CFS/FM…FM…and CFS compared to controls…. Pain, fatigue, quality of life, and CFS symptoms were equivalent for GWI, CFS/FM and CFS. Dolorimetry correlated with symptoms in GWI but not CFS or FM. Therefore, women with GWI, CFS and FM have systemic hyperalgesia compared to sedentary controls…. Molecular mechanisms of systemic hyperalgesia may provide new insights into the neuropathology and treatments of these nociceptive, interoceptive and fatiguing illnesses." [In this article, symptoms included: joint pain, muscle pain, exertional exhaustion, fatigue, disturbed sleep, throat symptoms, sore lymph nodes, and headache. Patients were not assessed for co-existing MTrPs, which may cause, mimic, or contribute to some or all of these symptoms. DJS]

Suskind AM, Berry SH, Suttorp MJ et al. 2012. Health-related quality of life in patients with interstitial cystitis/bladder pain syndrome and frequently associated comorbidities. Qual Life Res. [Oct 7 Epub ahead of print]. "To estimate the association of chronic non-urologic conditions [i.e., fibromyalgia (FM), chronic fatigue syndrome (CFS), and irritable bowel syndrome (IBS)] with health-related quality of life (HRQOL) in patients with interstitial cystitis/bladder pain syndrome (IC/BPS).....In patients with IC/BPS, the presence of FM, CFS, and IBS has a significant association with HRQOL, equivalent in impact to the bladder symptoms themselves. These results emphasize the importance of a multidisciplinary approach to treating patients with IC/BPS and other conditions."

Sutton BC, Opp MR. 2014. Musculoskeletal sensitization and sleep: Chronic muscle pain fragments sleep of mice without altering its duration. Sleep. 37(3):505–513. "Our findings of increased state transitions during musculoskeletal sensitization are consistent with these previous observations and contribute to the growing literature of the manner in which sleep is disrupted during chronic pain…. Clinical surveys identify that subjectively restorative sleep reduces next day pain, especially in patients with musculoskeletal pain. Conversely, reduction of daytime pain does not predict subsequent restorative sleep, and a lack of restorative sleep could further exacerbate pain. These relationships between sleep and pain suggest a 'vicious cycle' that perhaps may be broken by focusing on manipulation of sleep, not pain, as a critical target for intervention. In patients with chronic pain and sleep disturbance, it may be possible to alleviate or reduce pain by effective interventions to improve sleep quality using either targeted pharmacological treatments, behavioral treatments, or a combined approach. Indeed, recent studies demonstrate that cognitive behavioral therapy to treat insomnia in patients with fibromyalgia and other chronic pain conditions also is effective in reducing pain…. Collectively, our data support findings in the clinical literature that musculoskeletal pain fragments sleep."

Sutton BC, Opp MR. 2014. Sleep fragmentation exacerbates mechanical hypersensitivity and alters subsequent sleep-wake behavior in a mouse model of musculoskeletal sensitization. Sleep. 37(3):515–524. "Sleep deprivation, or sleep disruption, enhances pain in human subjects. Chronic musculoskeletal pain is prevalent in our society, and constitutes a tremendous public health burden. Although preclinical models of neuropathic and inflammatory pain demonstrate effects on sleep, few studies focus on musculoskeletal pain.… In conclusion, our data demonstrate that in this model, sleep fragmentation combined with musculoskeletal sensitization induces prolonged effects on mechanical hypersensitivity and sleep-wake behavior of mice. These effects result from synergistic interactions between sleep fragmentation and musculoskeletal sensitization, and do not result from sleep fragmentation or from musculoskeletal sensitization per se. Given the prevalence and increasing incidence of insufficient sleep in the United States, the relationship between chronic pain and sleep will continue to be a prominent public health issue."

Suzuki K, Yasuo Haruyama Y, Kobashi G et al. 2021. Central sensitization in neurological, psychiatric, and pain disorders: A multicenter case-controlled study. Pain Res Manag. Feb 15;2021:6656917. "We performed a multicenter case-controlled study including 551 patients with various neurological, psychological, and pain disorders... Patient diagnoses in this multicenter study included migraine, tension-type headache, medication overuse headache, Parkinson's disease, stroke, restless legs syndrome, neuropathy, fibromyalgia, complex regional pain syndrome, cervical/lumbar spine disease, chronic fatigue syndrome, and depression.... Our findings suggest that CSS may participate in these conditions as common pathophysiology."

Suzuki S, Castrillon-Watanabe EE, Arima T et al. 2016. Blood oxygenation of masseter muscle during sustained elevated muscle activity in healthy participants. J Oral Rehabil. [Oct 15 Epub ahead of print.] "These results suggest that SEMA (sustained elevated muscle activity) may lead to hypoxia in the masseter muscle and that the hemodynamic characteristics and muscle symptoms depend on the magnitude of muscle contractions." [This verifies a perpetuating factor for masseter TrPs. DJS]

Sverdrup B 2004.  Use less cosmetics – suffer less from fibromyalgia?  J Womens Health 13(2):187-194.  Reduced use of cosmetics resulted in a reduction in FMS symptoms.

Svendsen KB, Andersen S, Arnason S et al. 2005.  Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms.  Eur J Pain. 9(2):195-206.  “Breakthrough pain or transient worsening of pain in patients with an ongoing steady pain is a well known feature in cancer pain patients, but it is also seen in non-malignant pain conditions with involvement of nerves, muscles, bones or viscera.  We suggest that peripheral and/or central sensitization (hyperexcitability) may play a major role in many causes of BTP.”

Sweetser S. 2019. Abdominal wall pain: A common clinical problem. Mayo Clin Proc. 94(2):347-355. "Abdominal wall pain (AWP) is a common and underrecognized cause of chronic abdominal pain. The etiology of AWP varies. History and physical examination are critical to an accurate diagnosis of AWP. Trigger point injection using either a corticosteroid, a local anesthetic, or a combination of both often gives relief of pain and is of diagnostic and therapeutic value. Increased awareness of AWP as a cause of chronic, non visceral abdominal pain can prevent fruitless searches for intra-abdominal pathology and reduce medical costs."

Swick TJ. 2011. Sodium oxybate: a potential new pharmacological option for the treatment of fibromyalgia syndrome. Ther Adv Musculoskelet Dis. 3(4):167-178. "Fibromyalgia syndrome (FMS) is a common disorder, characterized by diffuse pain and tenderness, stiffness, fatigue, affective disorders and significant sleep pathology. A new set of diagnostic criteria have been developed which should make it easier for a busy clinician to diagnose the condition. US Food and Drug Administration (FDA) approved medications for the treatment of FMS have, for the most part, been geared to modulate the pain pathways to give the patient some degree of relief. A different kind of pharmacological agent, sodium oxybate (SXB), is described that is currently approved for the treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsy. SXB, an endogenous metabolite of the inhibitory neurotransmitter gamma-hydroxybutyrate, is thought to act independently as a neurotransmitter with a presumed ability to modulate numerous other central nervous system neurotransmitters. In addition SXB has been shown to robustly increase slow wave sleep and decrease sleep fragmentation. Several large clinical trials have demonstrated SXB's ability to statistically improve pain, fatigue and a wide array of quality of life measurements of patients with fibromyalgia. SXB is not FDA approved to treat fibromyalgia."

Szaboová E, Donic V, Albertova D et al. 2002. [Nocturnal cardiac dysrhythmias associated with obstructive sleep apnea]. Sb Lek. 103(1):79-83. [Article in Slovak] "The occurrence of cardiac dysrhythmias have been analysed in 16 adult patients suffering from obstructive sleep apnea syndrome of various severity randomly selected from more than 300 persons examined in our sleep laboratory from 1996 with a complex polysomnography…. The number of apneic episodes emerging in the first, second and third part of sleep was practically the same although their duration prolonged during the night culminating with an average of 25 sec…. OSA episodes caused a decrease of oxyhaemoglobin saturation to lower values during REM compared to NREM sleep…. Cardiac dysrhythmias occurred more frequently during and immediately after, than before OSA episodes demonstrating their causal relations." [People need to take sleep apnea seriously. DJS]

Szaboová E, Donic V, Tomori Z et al. 1997. [Obstructive sleep apnea as a cause of dysrhythmia in sudden cardiac death]. Bratisl Lek Listy. 98(7-8):448-453. [Article in Slovak] "Sleep apnoea is often accompanied by severe disturbances in heart rate and cardiac rhythm…. Various respiratory parameters were continuously recorded 6-9 hours during sleep in ten patients with sleep apnoea syndrome, parallel with direct ECG recording (8 cases) or Holter monitoring (2 cases). The rate, development and reversibility of various dysrrhythmias were evaluated…. Obstructive, central and mixed sleep apnoeas (OSA, CSA, MSA) and hypopnoea occurred in each patient (52.5%, 3.5%, 10% and 34%, respectively). Lighter dysrrhythmias (sinus arrest, atrioventricular block and occasional supraventricular premature contractions) were in patients with frequent CSA, whereas the most severe ones (higher degrees of AVCB, premature ventricular contractions and tachyarrhythmias) occurred during OSA. Stronger hypoxaemia and myocardial acidosis, as well as severe alteration in sympathetic and vagal tone probably contributed to the development of life-threatening brady- and tachyarrhythmias in OSA, based on alteration in effective refractory period and reentry phenomenon…. Dysrrhythmias often occur during OSA and they may result in acute cardiovascular complications. Due to their functional character and reversibility, the development of nocturnal dysrrhythmias can be prevented by early diagnosis and effective treatment of sleep related breathing disorders, which at the same time decreases, the risk of both cardiovascular complications and diseases." [Another study showing that people need to take sleep apnea seriously. DJS]

Szczot M, Pogorzala LA, Solinski HJ et al. 2017. Cell-type-specific splicing of Piezo2 regulates mechanotransduction. Cell Rep. 21(10):2760-2771. "Piezo2 is a mechanically activated ion channel required for touch discrimination, vibration detection, and proprioception. Here, we discovered that Piezo2 is extensively spliced, producing different Piezo2 isoforms with distinct properties. Sensory neurons from both mice and humans express a large repertoire of Piezo2 variants, whereas non-neuronal tissues express predominantly a single isoform. Notably, even within sensory ganglia, we demonstrate the splicing of Piezo2 to be cell type specific....Together, our results describe, at the molecular level, a potential mechanism by which transduction is tuned, permitting the detection of a variety of mechanosensory stimuli." Free Article [This may highlight one mechanism by which manual therapies can profoundly affect the body. DJS]

Tabatabaiee A, Ebrahimi-Takamjani I, Ahmadi A et al. Comparison of pressure release, phonophoresis and dry needling in treatment of latent myofascial trigger point of upper trapezius muscle. J Back Musculoskelet Rehabil. 2019;32(4):587-594. "Latent myofascial trigger point (LMTP) is a small hypersensitive area in skeletal muscles that becomes painful under compression or stimulation....Considering the significant, positive effects of all three methods, dry needling and phonophoresis seem to be more effective than pressure release."

Taddio A, Katz J. 2005.  The effects of early pain experience in neonates on pain responses in infancy and childhood.  Paediatr Drugs 7(4):245-257.  “Pre-term infants that are hospitalized as neonates and subjected to painful procedures appear to have a dampened response to painful procedures later in infancy.  Full-term neonates exposed to extreme stress during delivery, or to a surgical procedure, react to later noxious procedures with heightened behavioral responsiveness.  Studies in which analgesic agents (local anesthetics or opioids) have been administered prior to noxious procedures demonstrate less procedural pain and a reduction in the magnitude of long-term changes in pain behaviors.”  [Adequate pain control from infancy may prevent sensitizing the central nervous system and lessen the chance of developing FMS.  DJS]

Taggart HM, Arslanian CL, Bae S et al. 2003.  Effects of T’ai Chi exercise on fibromyalgia symptoms and health-related quality of life.  Orthop Nurs 22(5):353-60.  “T’ai Chi is potentially beneficial to patients with FM.”  [The high drop-out rate in the study may be due to lack of modification of the training, or to co-existing myofascial trigger points.  See reference article under “Starlanyl DJ, published in T’ai Chi Magazine.”

Tagoe CE, Sheth T, Golub E et al. 2019. Rheumatic associations of autoimmune thyroid disease: a systematic review. Clin Rheumatol. [Mar 29 Epub ahead of print] "To investigate specific disease patterns in the rheumatic manifestations associated with autoimmune thyroid disease (AITD) through a systematic literature review. We performed a systematic review using the Medline OVID, PubMed, EMBASE, and Web of Science databases through May 2018 for experimental and observational studies that explored the association of AITD with degenerative joint disease (DJD), osteoarthritis (OA), chronic widespread pain (CWP) and fibromyalgia syndrome (FMS), and seronegative inflammatory arthritis (IA).... Six observational studies reported up to 45% prevalence of DJD in AITD. Hand and spinal DJD were reportedly associated with higher odds of AITD. Twelve observational studies were retrieved reporting up to 62% prevalence of FMS in AITD patients. Four studies described the occurrence of seronegative IA in AITD patients. The rheumatic associations of AITD may manifest specific patterns of disease distinct from those of other well-defined autoimmune syndromes and contribute significantly to disease burden."

Taketa Y, Irisawa Y, Fujitani T. 2017. Ultrasound guided serrates posterior superior muscle block relieves interscapular myofascial pain. J Clin Anesth. 44:10-11.

Takla MKN. 2018. Low-frequency high-intensity versus medium-frequency low-intensity combined therapy in the management of active myofascial trigger points: A randomized controlled trial. Physiother Res Int. Aug 10:e1737. "Electrotherapeutic modalities have proven to be one of the best therapeutic options for myofascial pain syndrome, targeting the myofascial trigger points (MTrPs).... The aim was to compare between low-frequency, high-intensity burst transcutaneous electrical nerve stimulation CT (burst-TENS-CT) and medium-frequency, low-intensity amplitude modulated frequency CT (AMF-CT) on upper trapezius active MTrPs (A-MTrPs).... Within the scope of this study, both CT modalities were effective in increasing PPT and cervical lateral flexion ROM ( range of motion). Nonetheless, low-frequency, high-intensity burst-TENS-CT was shown to be superior over the medium-frequency, low-intensity AMF-CT in terms of reducing pain sensitivity and increasing ROM."

Talebian S, Otadi K, Ansari NN et al. 2012. Postural control in women with myofascial neck pain. J Musculoskel Pain. 20(1):25-30.Patients with myofascial TrPs in the neck area had difficulty standing on foam flooring, both with one-foot standing and bipedal standing. Foam flooring affected both the control group and the patient group, but the patients had a faster sway velocity and significantly greater displacement distance. The study revealed that patients with cervical TrPs have standing deficits in standing balance with the eyes open or closed. Postural impairments could be from proprioceptor dysfunction associated with neck TrPs. The use of foam flooring as a standing surface significantly worsened postural control, both during one-legged and bipedal stances. The foam disrupts the sensory information from cutaneous mechanoreceptors on the soles of the feet, contributing to postural instability that increased with TrP-related neck pain. Patients did recruit the ankle tissues in an attempt to compensate for the postural imbalance, stressing those muscles. [This has direct application for those patients who exercise on foam matted surfaces, for t'ai chi chuan, yoga and other forms in which postural balance is of importance. DJS.]

Tali D, Menahem I, Vered E et al. 2014. Upper cervical mobility, posture and myofascial trigger points in subjects with episodic migraine: Case-controlled study. J Bodyw Move Ther 18(4):569-575. "In view of these results, the association between prevalence of MTrPs and episodic migraines cannot be ignored."

Tamim H, Castel ES, Jamnik V et al. 2009. Tai Chi workplace program for improving musculoskeletal fitness among female computer users.  Work. 34(3):331-338.  “Results showed that the TC (Tai Chi) program was effective in improving musculoskeletal fitness and psychological well-being.”  “Significant improvements in physiological and psychological measures were observed, even at the large class sizes tested here, suggesting that TC has considerable potential as an economic, effective and convenient workplace intervention.”

Tamimi MA, McCeney MH, Krutsch J. 2009.  A case series of pulsed radiofrequency treatment of myofascial trigger points and scar neuromas.  Pain Med. 10(6):1140-1143.  “…PRF (pulsed radiofrequency) could be a minimally invasive, less neurodestructive treatment modality for these painful conditions and that further systematic evaluation of this treatment approach is warranted.”

Tan AC, Jaaniste T, Champion D. 2019. Chronic widespread pain and fibromyalgia syndrome: Life-course risk markers in young people. Pain Res Manag. May 5;2019:6584753. "The early-life risk markers identified by extensive literature review with best evidence for potential causal influence on the development and progression of CWP and FMS include genetic factors, premature birth, female sex, early childhood adversity, cognitive and psychosocial influences, impaired sleep, primary pain disorders, multiregional pain, physical trauma, infectious illness, obesity and inactivity, hypermobility of joints, iron deficiency, and small-fiber polyneuropathy. The case history illustrates the potential etiological influence of multiple risk markers offset by personal resilience."

Tanrikut A, Nadire O, Huseyin AK et al. 2001.  High voltage galvanic stimulation in myofascial pain syndrome.  J Muscoloskel Pain 11(2):11-15.  HGVS can be a useful treatment for myofascial pain.

Tanriverdi O. 2014. Is a new perspective for definition and diagnostic criteria of fibromyalgia in early stage cancer patients necessary? Med Hypotheses. [Jan 27 Epub ahead of print.] "Fibromyalgia is a most common pain syndrome characterized by the presence of chronic widespread pain and tenderness with manual palpation. However there is not enough data about frequency of fibromyalgia syndrome in patients with cancer. How often FM is being used in oncological practice and how are we managing this case by medical oncologists. Widespread pain index and symptom severity scale are not clear enough in patients with cancer when ACR-2010 diagnostic criteria for FM are considered. In conclusion, there is it may more prevalence of fibromyalgia in patients with cancer. For the diagnosis of fibromyalgia, (there may need to) be new diagnostic criteria for early-stage cancer patients."

Tantanatip A, Patisumpitawong W, Lee S.2021. Comparison of the effects of physiologic saline interfascial and lidocaine trigger point injections in treatment of myofascial pain syndrome: A double-blind randomized controlled trial. Arch Rehabil Res Clin Transl. Mar 9;3(2):100119. "Physiologic saline interfascial and lidocaine trigger point injections effectively decreased MPS pain in the upper trapezius muscle at 2 and 4 weeks after treatment. However, lidocaine trigger point injection demonstrated better pain improvement at 10 minutes after treatment."

Taraktas A, Mesci N, Ozturk G et al. 2016. Pregabalin-induced hyperprolactinemia in a patient with fibromyalgia: A case report. North Clin Istanb. 3(3):233-236. "Several pharmacological and nonpharmacological modalities have been proposed for the treatment of fibromyalgia syndrome (FMS), a common rheumatic disease. Pregabalin is suggested as a first-step medication for FMS in the newest guidelines. Drowsiness, dizziness, and peripheral edema are well-known side effects of pregabalin; however, mastalgia is rarely seen. Presently described is a case of FMS in a patient who developed mastalgia and hyperprolactinemia (HPL) while taking pregabalin." Free Article

Targino RA, Imamura M, Kaziyama HH et al. 2002.  Pain treatment with acupuncture for patients with fibromyalgia.  Curr Pain Headache Rep. 6(5):379-383.  This review is a comparison of acupuncture and other therapies in the relief of FMS.  Traditional acupuncture resulted in FMS improvement.

Tas A, Emrullah Hayta E, Karadag A, et al. Potassium ion channel protein (KCNH) levels in patients with fibromyalgia syndrome. Cell Mol Biol (Noisy-le-grand). 2022 Feb 4;67(5):451-457. "The purpose of this study was to measure the plasma levels of potassium ion channel proteins (human KCNH2, KCNH6 and KCNH7) in FM patients and healthy control subjects…. In comparisons between FM and control groups, KCNH2 plasma levels was found to be significantly lower in the FM group. No significant correlation was found between plasma levels of KCNH2, KCNH6 and KCNH7 protein levels and VAS score of patients with FM. The KCNH2 protein had a high homology score with 9 proteins. The plasma levels of KCNH2 FM patients were found to be lower than those of the healthy control subjects, no difference was determined in respect of the plasma levels of KCNH6 and KCNH7."

Tasali E, Leproult R, Ehrmann DA et al. 2008. Slow-wave sleep and the risk of type 2 diabetes in humans.  Proc Natl Acad Sci U S A 105(3):1044-1049.  “These findings demonstrate a clear role for SWS in the maintenance of normal glucose homeostasis.  Furthermore, our data suggest that reduced sleep quality with low levels of SWS (slow-wave sleep), as occurs in aging and in many obese individuals, may contribute to increase the risk of type 2 diabetes.”

Taskesen F, Cezairli B. 2020. The effectiveness of the masseteric nerve block compared with trigger point injections and dry needling in myofascial pain. Cranio. Sep 16;1-6. "Results of the present study indicate that MNB (masseteric nerve block) was not as effective as trigger point injection with local anesthetic or dry-needling in the management of masticatory myofascial pain".

Taskiran OO, Albayrak H, Topaloglu M, et al. Effect of ultrasound-guided rhomboid interfascial plane block on pain severity, disability, and quality of life in myofascial pain syndrome - A case series with one-year follow-up. Pain Physician. 2023 Nov;26(7):E815-E822. Pain severity was statistically significantly reduced in approximately 90%, 60-70%, and 50% of the chronic MPS patients at the first week, first month, and first year following injection, respectively. Disability scores improved significantly in 70% and 56% of those patients at the first month and first-year follow-up. Improvement in the quality of life was observed at the first month and maintained at the first-year follow-up. Conclusions: Our study demonstrated that RIB might be an effective long-term treatment option for MPS in the reduction of pain and disability, improvement of quality of life and overall patient satisfaction.

Tassain V, Attal N, Fletcher D et al. 2003.  Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-cancer pain.  Pain 104(1-2):389-400. “...twelve months treatment with oral morphine does not disrupt cognitive functioning in patients with chronic non-cancer pain and instead results in moderate improvement of some aspects of cognitive functioning as a consequence of the pain relief and concomitant improvement of well-being and mood.”

Tatum WO, Langston ME, Acton EK. 2016. Fibromyalgia and seizures. Epileptic Disord. [May 20 Epub ahead of print.] "The purpose of this case-matched study was to determine how frequently fibromyalgia is associated with different paroxysmal neurological disorders and explore the utility of fibromyalgia as a predictor for the diagnosis of psychogenic non-epileptic seizures.… Forty-three percent of those with fibromyalgia had a non-paroxysmal, neurological primary clinical diagnosis, most commonly chronic pain. Paroxysmal events were present in 57% of fibromyalgia patients and 54% of case-matched controls. Among patients with fibromyalgia and paroxysmal disorders, 11% had epileptic seizures, 74% had psychogenic non-epileptic seizures, and 15% had physiological non-epileptic events, compared to case-matched controls with 37% epileptic seizures, 51% psychogenic non-epileptic events, and 12% physiological non-epileptic events (p = 0.009). Fibromyalgia was shown to be a predictor for the diagnosis of psychogenic non-epileptic seizures in patients with undifferentiated paroxysmal spells. However, our results suggest that the specificity and sensitivity of fibromyalgia as a marker for psychogenic nonepileptic seizures in a mixed general neurological population of patients is less than previously described."

Tauben DJ, Loeser JD. 2013. Pain education at the University of Washington School of Medicine. J Pain. 14(5):431-437. "There is a compelling need for implementation of new approaches to pain medicine education in both medical and other health science schools in response to the increasing evidence of inadequate and insufficient pain medicine education in both the U.S. and elsewhere. The UWSOM has recently increased pain curriculum time spent and the future practice relevance of its pain education by implementing a 4-year integrated curriculum tailored to match both the learning level and clinical experience, including most of the ISAP's recommended content, while emphasizing the educational needs of future primary care physicians, those who are and will continue to manage the vast majority of patients seeking medical advice and treatment of both acute and chronic pain."

Taw LB, Henry E. 2016. Acupuncture and trigger point injections for fibromyalgia: East-West Medicine case report. Altern Ther Health Med. 22(1):58-61. "Fibromyalgia is a clinical syndrome characterized by chronic widespread pain that is often accompanied by (1 or more) concomitant symptoms (e.g., fatigue, poor sleep, cognitive alterations, and mood disturbances). In 2005, an estimated 5 million people in the United States suffered from fibromyalgia, and its growing effect on health-related quality of life is substantial. An increasingly popular hypothesis proposes that noxious, peripheral sensory input might contribute to the initiation and perpetuation of the diffuse pain seen in patients with fibromyalgia. That theory has led to the evaluation of multiple interventions to stimulate distal areas as a means to modulate the peripheral and central nervous systems. It has been the authors' experiences that the combination of trigger point injections and acupuncture provides improved clinical outcomes. In the current article, the authors present a case report of a patient with fibromyalgia who was successfully treated with an integrative approach that combined acupuncture with trigger point injections."

Taylor BK, Sinha GP, Donahue RR et al. 2019. Opioid receptors inhibit the spinal AMPA receptor Ca2+ permeability that mediates latent pain sensitization. Exp Neurol. 314:58-66. "We conclude that after tissue injury, dorsal horn (of the spinal cord) AMPARs (α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptors) retain a Ca2+ permeability that underlies LC S. (latent central sensitization ). Because of their effectiveness in reducing naltrexone-induced reinstatement of hyperalgesia and potentiation of AMPAR-evoked Ca2+ signals, CP-AMPAR inhibitors are a promising class of agents for the treatment of chronic inflammatory pain."

Teachey WS. 2004.  Otolaryngic myofascial pain syndromes.  Curr Pain Headache Rep. 8(6):457-462.  Many unexplained ear, nose, throat, head and neck dysfunctions that cannot be explained otherwise fit the diagnosis of myofascial dysfunction, and TrP therapy is effective for these symptoms.

Teachey WS, Wijtmans EH, Cardarelli F et al. 2012. Tinnitus of myofascial origin. Int Tinnitus J. 17(1):70-73. "Tinnitus in some instances is due to a primary muscle disorder: myofascial dysfunction of the muscles of the head and neck. Tinnitus of this origin can be diminished in some cases, and completely abolished in others, by appropriate treatment; this includes trigger point deactivation, specific exercises, and treatment of the underlying causes of the muscle dysfunction. "

Tecco S, Marzo G, Crincoli V et al. 2012. The prognosis of myofascial pain syndrome (MPS) during a fixed orthodontic treatment. Cranio. 30(1):52-71. "Among treatments in the literature for myofascial pain syndrome (MPS), the most reliable therapies in dentistry are spray and stretch, and, although less frequently used, anesthetic injection. Adult MPS subjects are often treated using fixed orthodontic therapy for resolution of malocclusion....The purpose of this study was to analyze the prognosis of MPS during orthodontic treatment of subjects with malocclusion, initially diagnosed as having MPS. The analysis covered the medical records of 91 young adult Caucasians scheduled for orthodontic treatment for various malocclusions. Thirty-seven of the patients were initially diagnosed as also having MPS (T0). Thirty patients began the orthodontic treatment and were recalled for a re-evaluation of MPS after dental alignment and dental class correction was achieved (T1). A wait-and-see strategy was applied in seven subjects who were included as the control subjects. They received no treatment for MPS. At T1, a statistically significant decrease was observed in the study group in the presence of any clicking or creaking noises from the jaw joint, a significant jaw joint and jaw muscle pain reduction, and a quality of life improvement. Among patients who were depressed at the beginning of treatment, the majority felt better at the follow-up evaluation. On muscular palpation, a statistically significant decrease was found on the visual analogic scale value of the middle fibers of the temporalis muscle, temporalis tendon, clavicular and sternal division of the sternocleidomastoid muscle, masseter muscles, and posterior cervical muscles. The temporalis and the masseter muscles showed a significant decrease in the number of subjects with trigger points (TrPs) in all areas in the study group, after treatment. The digastric and sternocleidomastoid muscles also showed a significant reduction in the number of subjects with TrPs. Subjects with MPS and malocclusion were treated using a fixed orthodontic treatment. They showed improvement, although no resolution, in the signs and symptoms of MPS, compared with the untreated control group."

Teixeira MJ, Yeng LT, Garcia OG et al. 2011. Failed back surgery pain syndrome: therapeutic approach descriptive study in 56 patients. Rev Assoc Med Bras. 57(3):286-291. [English, Portuguese] "The authors show the clinical evaluation and follow-up results in 56 patients diagnosed with a failed back surgery pain syndrome. ... In patients with a post-laminectomy syndrome, postoperative pain was more severe than preoperative pain from a herniated disk. A myofascial component was found in most patients."

Telli H, Özdemir C. 2024. Is nociplastic pain, a new pain category, associated with biochemical, hematological, and inflammatory parameters? Curr Med Res Opin. 2024 Jan 11:1-13. "In our study, it was observed that levels of vitamin D in individuals with nociplastic pain were low, while erythrocyte sedimentation rate, C-reactive protein, and Neutrophil/Lymphocyte ratio were high, and hemoglobin and ferritin levels were elevated. Furthermore, these findings were found to be associated with both the presence of pain and the severity of pain assessed using the visual analog scale."

Ten Brink AF, Bultitude JH.2022. Visual sensitivity in complex regional pain syndrome and fibromyalgia: An online study. Perception. Mar 3;3010066211072641. "Complex regional pain syndrome (CRPS) and fibromyalgia are chronic pain conditions associated with changes in the central nervous system, possibly leading to enhanced visual sensitivity…. Respondents with CRPS or fibromyalgia reported more visual discomfort than pain-related and pain-free controls while viewing striped patterns and a circle, with no effect of spatial frequency. They reported more pain while viewing a nonreversible square, but not reversible figures (Necker Cube, Duck/Rabbit). Finally, they reported more daily visual sensitivity than pain-related and pain-free controls. Suppressing visual cortical activity might benefit people with CRPS or fibromyalgia."

Ten Brink AF, Goebel A, Berwick R et al. 2020. Sensitivity to ambient temperature increases in fibromyalgia and CRPS. Pain Med. Dec 25;21(12):3726-3729.

Ten Brink AF, Peters L, Kompouli PI et al. 2020. Bodily changes and sensory sensitivity in complex regional pain syndrome and fibromyalgia. Pain. [Feb 10 Epub ahead of print] "Complex regional pain syndrome (CRPS) and fibromyalgia are chronic pain conditions of unexplained origins. In addition to symptoms in the diagnostic criteria, patients can report changes to vision and other sensations or bodily functions…. After controlling for covariates, respondents with CRPS and/or fibromyalgia reported more somatic symptoms, changes in movement and biological responses, pain/discomfort/distress triggers, and pain intensifiers than pain(-free) control groups. Fibromyalgia specifically related to changes in vision and hearing; urinary/intestinal function; and drinking and eating. CRPS changes related to changes in hair, skin, and nails; and infection and healing. The CRPS+fibromyalgia group presented with features of both disorders with minimal additional stressors or symptoms over and above these."

Ten Brink AF, Proulx MJ, Bultitude JH. 2021. Validation of the Leiden Visual Sensitivity Scale and Visual Discomfort Scale in chronic pain conditions. Perception. Mar 31;3010066211005327. "Discomfort provoked by normally innocuous visual stimuli has been reported by people with chronic pain. Visual discomfort may be higher in pain conditions in which central sensitization is implicated, such as Complex Regional Pain Syndrome (CRPS) and fibromyalgia. In an online study, we validated the Leiden Visual Sensitivity Scale (L-VISS) and Visual Discomfort Scale (VDS) in people with CRPS (n =57), fibromyalgia (n =75), and general chronic pain (n =53); investigated whether these groups and pain-free controls (n =125) differed in visual discomfort; and evaluated the effect of age…. Both scales were positively related with experimentally induced visual distortions for mid-spatial frequency striped patterns, suggesting good construct validity…. Visual discomfort was highest in the fibromyalgia group, followed by the CRPS group."

Tenberg S, Nosaka K, Wilke J. 2022. The relationship between acute exercise-induced changes in extramuscular connective tissue thickness and delayed onset muscle soreness in healthy participants: A randomized controlled crossover trial. Sports Med Open Apr 28;8(1):57. "The present study aimed to investigate the effect of eccentric elbow flexor exercise on the morphology of the biceps brachii ECT (extramuscular connective tissue). In view of the high nociceptive capacity of the ECT, an additional objective was to elucidate the potential relationship between ECT damage and the occurrence of delayed onset muscle soreness (DOMS)…. Collectively, these results suggest an involvement of the ECT changes in delayed onset muscle soreness." [Changes in the fascia may be involved with DOMS.]

Tennant F. 2013. The physiologic effects of pain on the endocrine system. Pain Ther. 2(2):75-86. Severe pain can affect the endocrine system profoundly. These hormonal changes can indicate the physiological presence of severe pain, as well as the need for hormone replacement. Acute pain affects the hypothalamic-pituitary-adrenal axis; the balance between these hormones. Once the pain becomes chronic, the hormone levels cannot be sustained, and even the stress hormones may drop below normal. This does not mean that the pain has gone away. "Some hormones are so critical to pain control that a deficiency may enhance pain and retard healing." This article discussed the interaction among thyroid, adrenal, gonad, and other hormones on the central nervous system (CNS). [This article is an important one. I urge everyone to get a copy–it is free on the Internet. The author, Dr. Forest Tennant, has written an extremely fine article, and I urge every chronic pain patient to read it and see that their doctors and other care professionals get a copy. DJS]

Tennant F. 2009.  Brain atrophy with chronic pain – A call for enhanced treatment.  Pract Pain Manage. 9(2):12-14,44.  Chronic pain can cause areas of the brain to shrink by as much as 11%, similar to that lost by 1-2 decades of aging.  “The decrease in the prefrontal cortex and the thalamus…was related to the duration of time spent in pain.  Every year of pain appeared to decrease grey matter by 1.3 cubic centimeters….Brain atrophy, along with altered brain physiology and neurochemistry, now joins the risk profile of undertreated chronic pain.”  [This study was done on chronic back pain patients.  It indicates that undertreated pain is an interactive condition of itself, although a preventable one. DJS]

Tennant F, Hermann L. 2001.  (231) use of transmucosal fentanyl in non-malignant, chronic pain.  Pain Med. 2(3):252-253.  “Reported reasons for widespread patient acceptance included TF’s fast action, fewer bed-bound days, increased energy, decreased use of other opioids, less depression, and fewer emergency room visits.  This pilot study indicates that TF is effective and desired as a preferential opioid for breakthrough pain by a high percentage of chronic, non-malignant pain patients.”

Tentindo GS, Fishman SM, Li CS. 2018. The prevalence and awareness of sleep apnea in patients suffering chronic pain: an assessment using the STOP-Bang sleep apnea questionnaire. Nat Sci Sleep. 10:217-224. "Some patient subsets are at higher risk of sleep apnea, including patients with chronic pain.... Chronic pain is often treated with opioids which may decrease both the central respiratory drive and the patency of the upper airway, potentially contributing to this sleep disorder. Using a self-reporting questionnaire approach in the chronic pain population, this study surveyed patient and caregiver awareness surrounding the risk of sleep apnea. In addition, we looked at the influence of opioid therapy on the prevalence of sleep apnea.... Against expectation, opioids did not increase the prevalence of sleep apnea in our study population.... Chronic pain patients had a high risk of sleep apnea, regardless of opioid prescription. Most patients were unaware of their increased risk and denied undergoing the necessary testing.

Teo WP, Kannan A, Loh PK et al. 2014. Poor Tolerance of Motor Cortex rTMS in Chronic Migraine. J Clin Diagn Res. 8(9):MM01-2. Of nine patients, only three completed the study due to significant worsening of symptoms. "Although the study was terminated prematurely, the high dropout rate (50%) due to worsening headaches suggested that rTMS over the motor cortex is poorly tolerated in chronic migraine."

Teoh SH. 2016. Angry patient with fibromyalgia: Diagnosis and management in primary care. Med J Malaysia. 71(6):351-353. "I report a case of a 40-year-old lady who presented with symptoms and signs suggestive of fibromyalgia but was disregarded by attending doctor. She was infuriated and lodged a complaint to Family Medicine Specialist (FMS) whereby further assessment confirmed the diagnosis of fibromyalgia and subsequently treated in primary care setting." Free Article

Tepper S J. 2004.  New thoughts on sinus headache.  Allergy Asthma Proc 25(2):95-96. “Sinus headaches are usually severely disabling migraines, misdiagnosed and mistreated, with 61% of patients receiving antibiotic prescriptions for noninfectious causes, thus failing the patients and, in addition, contributing to a serious public health problem.”

Tereshko Y, Dalla Torre C, Lettieri C, et al.2022 Subcutaneous BoNT/A injection for intractable pain and disability in complex regional pain syndrome: A case report. Toxins (Basel). Jun 16;14(6):411."We treated a 51-year-old woman with refractory Complex Regional Pain Syndrome type I (CRPS-I) involving her left hand and forearm with subcutaneous injections of BoNT/A. The injections were performed every 3 months, with a total of six treatments. Each treatment was able to effectively improve pain and motor impairment; however, the duration of the effect was limited to only a few months."

Terkelsen AJ, Birklein F. Complex regional pain syndrome or limb pain: A plea for a critical approach. J Pain Res. 2022 Jul 8;15:1915-1923.Most frequently, complex regional pain syndrome (CRPS) develops after a trauma and affects distal parts of the limbs. Early recognition and initiation of adequate treatment is crucial for a favorable outcome. On the other hand, misdiagnosing other disorders as CRPS is detrimental because more appropriate treatment may be withheld from the patients. Despite intensive research, a specific biomarker or paraclinical measure for CRPS diagnosis is still lacking. Instead, clinical criteria approved by the International Association for the Study of Pain (IASP) and latest adapted in 2019 are central for diagnosing CPRS. Thus, the CRPS diagnosis remains challenging with the risk of a "deliberate diagnosis" for unexplained pain, while at the same time a delayed CRPS diagnosis prevents early treatment and full recovery. CRPS is a diagnosis of exclusion. To clinically diagnose CRPS, a vigorous exclusion of "other diseases that would better explain the signs and symptoms" are needed before the patients should be referred to tertiary centers for specific pain treatment. [I disagree.. CRPS is not a diagnosis of exclusion. I have CRPS, FM, chronic myofascial pain and dysfunction, and at least 17 other chronic conditions. One of these diagnoses does not preclude the others. DJS]

Terkelsen AJ, Gierthmuhlen J, Finnerup NB et al. 2014. Bilateral Hypersensitivity to Capsaicin, Thermal, and Mechanical Stimuli in Unilateral Complex Regional Pain Syndrome. Anesthesiology. [Mar 11 Epub ahead of print.] "Complex regional pain syndrome is multifactorial. Exaggerated inflammatory responses to limb injury may be involved. The authors hypothesized that capsaicin-induced pain and neurogenic inflammation (skin perfusion and flare area) are increased in patients with complex regional pain syndrome compared with that in controls…. The main finding is bilaterally increased capsaicin-induced pain in patients compared with controls. The flare response to capsaicin was normal, suggesting that the increased pain response was not due to increased neurogenic inflammation. The bilateral hypersensitivity to painful chemical, thermal, and mechanical stimuli not confined to the innervation area of a peripheral nerve or root cannot be explained by a regional change and may partly be due to central sensitization."

Terlemez R, Ercalık T. Effect of piriformis injection on neuropathic pain. Agri. 2019 Nov;31(4):178-182. "All of the patients received 4 mL of lidocaine 2%+1 mL of betamethazone to the piriformis muscle under the guidance of ultrasound.... A piriformis injection was found to be effective for both somatic and neuropathic pain in piriformis syndrome patients. Long-term follow-up is needed in order to consider this option alongside other treatment alternatives, like botulinum toxin and myofascial release.

Terrasa JL, Barros-Loscertales A, Montoya P et al. 2020.Self-regulation of SMR power led to an enhancement of functional connectivity of somatomotor cortices in fibromyalgia patients. Front Neurosci. Mar 19;14:236. "In the SMR training group, four patients achieved the objective of SMR modulation in more than 70% of the trials from the second training session (good responders), while five patients performed the task at the chance level (bad responders). Good responders to the neurofeedback training significantly reduced pain and increased both SMR power modulation and functional connectivity of motor and somatosensory related areas during the last neurofeedback training session, whereas no changes in brain activity or pain were observed in bad responders or participants in the sham group. In addition, we observed that good responders were characterized by reduced impact of fibromyalgia and pain symptoms, as well as by increased levels of health-related quality of life during the pre-training sessions." [This study used a method to find those with FM who would benefit best from the use of neurofeedback to modulate and coordinate signals concerning these areas of the brain. This treatment could be affecting co-existing chronic myofascial pain and dysfunction due to trigger points as well. DJS]

Terry RH, Palmer ST, Rimes KA. 2015. Living with joint hypermobility syndrome: patient experiences of diagnosis, referral and self-care. Fam Pract. [Apr 24 Epub ahead of print.] "Results: Pain, fatigue, proprioception difficulties and repeated cycles of injury were among the most challenging features of living with JHS. Participants perceived a lack of awareness of JHS from health professionals and more widely in society and described how diagnosis and access to appropriate health-care services was often slow and convoluted. Education for patients and health professionals was considered to be essential. Conclusions: Timely diagnosis, raising awareness and access to health professionals who understand JHS may be particularly instrumental in helping to ameliorate symptoms and help patients to self-manage their condition. Physiotherapists and other health professionals should receive training to provide biopsychosocial support for people with this condition."

Tershner SA, Mitchell JM, Fields HL. 2000.  Brainstem pain modulating circuitry is sexually dimorphic with respect to mu and kappa opioid receptor function.  Pain 85(1-2):153-159.  “There are sex differences in the pain modulating potency of the opioid analgesics...”

Terzi R, Terzi H, Kale A. 2015. [Evaluating the relation of premenstrual syndrome and primary dysmenorrhea in women diagnosed with fibromyalgia.] Rev Bras Reumatol. [Feb 16 Epub ahead of print.] [Article in Portuguese] "There is an increased frequency of premenstrual syndrome and dysmenorrhea in FM patients. The patients with high symptom severity scores and high depression scores among the FM patients are at risk of PMS and PD." Free Article [The increase may be due to myofascial trigger points, but these were not mentioned. DJS]

Terzi R, Yılmaz Z. 2015. Evaluation of pain sensitivity by tender point counts and myalgic score in patients with and without obstructive sleep apnea syndrome. Int J Rheum Dis. Aug 10. [Epub ahead of print] "The differences noted between OSAS patients and the control group with respect to myalgic score and the number of tender points suggest that there might be a relation between OSAS and pain sensitivity. There might be an association between low oxygen saturation and total myalgic score."

Tewari S, Madabushi R, Agarwal A et al. 2017. Chronic pain in a patient with Ehlers-Danlos syndrome (hypermobility type): The role of myofascial trigger point injections. J Bodyw Mov Ther. 21(1):194-196. "Chronic widespread musculoskeletal pain is a cardinal symptom in hypermobility type of Ehler Danlos Syndrome (EDS type III). The management of pain in EDS, however, has not been studied in depth. A 30 year old female, known case of EDS, presented to the pain clinic with complaints of severe upper back pain for 6 months. Physical examination of the back revealed two myofascial trigger points over the left rhomboids and the left erector spinae. Local anesthetic trigger point injections were given at these points, followed by stretching exercises under analgesic cover for the first week. After 1 week the patient reported 60-80% pain relief. This case highlights that we must keep a high index of suspicion for the more treatable causes of pain like myofascial pain syndrome in patients suffering from EDS, and should address it promptly and appropriately in order to maximize patient comfort."

Thaiss CA, Zeevi D, Levy M et al. 2014. Transkingdom control of microbiota diurnal oscillations promotes metabolic homeostasis. Cell 159(3):514-529. "This study from Israel found that mice treated with jet-lagged bacteria can produce changes in the mice metabolism creating a tendency to gain weight, including glucose intolerance. This may have implications for shift workers and frequent flyers across time zones."

Thakral M, Shi L, Foust JB et al. 2016. Pain quality descriptors in community-dwelling older adults with nonmalignant pain. Pain. 157(12):2834-2842. "Findings from this study indicate that older adults have multiple pain-associated conditions that likely reflect multiple physiological mechanisms for pain. Linking pain qualities with other associated pain characteristics serve to develop a multidimensional approach to geriatric pain assessment.." [Slowly it is being discovered that many of us have one or more conditions, and the co-existing conditions are important. DJS]

Thawale R, Alva S, Niraj G. 2019. Ultrasound-guided intermediate cervical plexus block with depot steroids in the management of refractory neck pain secondary to cervicothoracic myofascial pain syndrome: A Case Series. A A Pract. [Oct 4 Epub ahead of print] "Persistent cervicothoracic myofascial pain is a common condition that causes loss of function and can result in significant health care costs. The underlying cause is tender trigger points that result in impaired muscle function. Standard treatment includes physiotherapy, medications, acupuncture, and trigger point injections. Patients who fail to respond have very limited treatment options. The authors present a novel treatment in 2 patients presenting with severe unilateral cervicothoracic myofascial neck pain that failed to respond to standard treatment. The novel treatment, ultrasound-guided intermediate cervical plexus block with depot steroids, produced significant and durable pain relief in the 2 patients."

Theadom A, Cropley M, Humphrey KL. 2007.   Exploring the role of sleep and coping in quality of life in fibromyalgia.  J Psychosom Res. 62(2):145-151.  “Sleep quality was significantly predictive of pain, fatigue, and social functioning in patients with FMS....Interventions designed to improve sleep quality may help to improve health-related quality of life for patients with FMS.”

Theoharides TC. 2007.  Treatment approaches for painful bladder syndrome/interstitial cystitis.  Drugs. 67(2):215-235.  “Lack of early diagnosis and treatment [of painful bladder] can affect outcomes and leads to the development of hyperalgesia/allodynia.”

Theoharides TC, Stewart JM, Hatziagelaki E et al. 2015. Brain "fog," inflammation and obesity: key aspects of neuropsychiatric disorders improved by luteolin. Front Neurosci. 9:225. "Brain 'fog' is a constellation of symptoms that include reduced cognition, inability to concentrate and multitask, as well as loss of short and long term memory. Brain 'fog' characterizes patients with autism spectrum disorders (ASDs), celiac disease, chronic fatigue syndrome, fibromyalgia, mastocytosis, and postural tachycardia syndrome (POTS), as well as 'minimal cognitive impairment,' an early clinical presentation of Alzheimer's disease (AD), and other neuropsychiatric disorders. Brain 'fog' may be due to inflammatory molecules, including adipocytokines and histamine released from mast cells (MCs) further stimulating microglia activation, and causing focal brain inflammation. Recent reviews have described the potential use of natural flavonoids for the treatment of neuropsychiatric and neurodegenerative diseases. The flavone luteolin has numerous useful actions that include: anti-oxidant, anti-inflammatory, microglia inhibition, neuroprotection, and memory increase….Methylated luteolin analogs with increased activity and better bioavailability could be developed into effective treatments for neuropsychiatric disorders and brain 'fog.'" Free PMC Article

Thiagarajah AS, Eades LE, Thomas PR et al. 2014. GILZ: Glitzing up our understanding of the glucocorticoid receptor in psychopathology. Brain Res. [Jun 12 Epub ahead of print.] "Dysfunction of the hypothalamic-pituitary-adrenal axis, particularly the glucocorticoid receptor, is a commonly implicated link between stress and psychopathology. GR abnormalities are frequently reported in depression, and these anomalies must be resolved before depressive symptoms remit. This biological finding is rendered clinically relevant by the knowledge that only select antidepressants alter GR function. The relationship between GR dysfunction and other diseases associated with psychiatric stress, such as post-traumatic stress disorder (PTSD) and fibromyalgia, is also documented. However, as laboratory constraints limit the utility of GR testing, other measures of GR activity, such as levels of GR-induced genes, may have greater clinical value. In this review, glucocorticoid-induced leucine zipper (GILZ), a product of GR-initiated gene transcription, will be discussed in the context of GR dysfunction in psychopathology."

Thieme K, Gracely RH. 2009.  Are psychological treatments effective for fibromyalgia pain?  Curr Rheumatol Rep. 11(6):443-450.  This is a review based on literature search, and so based on studies that do not take into consideration the co-existing conditions including TrPs, which now have been found to occur in all FM patients.  This may have something to do with the FM heterogenicity mentioned in this review.  It basically compared the effects of different types of psychological treatments.  Remembering the above caveats, relaxation as a single therapy was shown to be not helpful, hypnotherapy and writing intervention were mildly effective, but operant-behavioral therapy and cognitive behavioral therapy were considered effective for FM pain.  [Although psychological mechanisms can be helpful adjuncts, if FM pain is being maintained by myofascial TrPs, and they are due to defects in calcium channels, psychological methods cannot be considered treatment of FM pain, but they can help people with FM cope with the pain, the other symptoms, and the lack of support and understanding by others, often including the medical care team.  Adequate pain control and identification and control of TrP perpetuating factors might do a great deal more to help “FM” pain. DJS]

Thieme K, Jung K, Mathys MC, et al. 2022. Cardiac-gated neuromodulation increased baroreflex sensitivity and reduced pain sensitivity in female fibromyalgia patients. J Clin Med. 2022 Oct 21;11(20):6220. "The study presents a novel approach of programing pain inhibition in chronic pain patients based on the hypothesis that pain perception is modulated by dysfunctional dorsal medial nucleus tractus solitarii (dmNTS) reflex arcs that produce diminished baroreflex sensitivity (BRS) resulting from a conditioned response... Baroreceptor training may reduce FM pain by BRS-mediated effects on intrinsic pain regulatory systems and autonomic responses."

Thieme K, Turk DC. 2005.  Heterogeneity of psychophysiological stress responses in fibromyalgia syndrome patients.  Arthritis Res Ther. 8(1):R9  “The identification of low baseline muscle tension in FMS is discrepant with other chronic pain syndromes and suggests that unique psychophysiological features may be associated with FMS.  The different psychophysiological response patterns within the patient sample support the heterogeneity of FMS.”

Thieme K, Turk DC, Gracely RH et al. 2014. The relationship among psychological and psychophysiological characteristics of fibromyalgia patients. J Pain. [Nov 26 Epub ahead of print.] "This study examined the relationship of psychophysiological response patterns in fibromyalgia (FM) with psychological characteristics and comorbid mental disorders. Surface electromyographic data (EMG), systolic (SBP) and diastolic blood pressure (DBP), heart rate (HR), and skin conductance levels (SCL) were recorded continuously during baseline, stress, and relaxation tasks. Cluster analysis revealed 4 subgroups of patients who differed on pain characteristics, cognitive, affective, and behavioral responses to pain and stress. The largest group (46.7%) was characterized by elevated BP levels and stress reactivity (a disposition assumed to be a vulnerability factor for the development of diseases), associated with pain, anxiety, physical interference, low activity, and pain behaviors. A second group (41.6%) showed low baseline BP and reactivity, and high activity and stress. A third group (9.2%) displayed high baseline SCL, reactivity and depression, and a fourth small group (2.5%) with elevated EMG baseline and reactivity with high levels of anxiety and depression. These data suggest that unique psychophysiological response patterns are associated with psychological coping and mental disorders in FM patients. The identification of the mechanisms that contribute to these group differences will further our understanding of the mechanisms involved in the development and maintenance of FM and suggest differential treatment strategies…. Demonstration of distinct, homogeneous subgroups is an important step towards personalized, mechanism-oriented treatments."

Thieme V. 2016. [Orofacial pain - Trigeminal neuralgia and posttraumatic trigeminal neuropathy: Common features and differences]. Schmerz. [Jan 27 Epub ahead of print.] [Article in German] "Neuropathic pain is the result of a lesion or disease of the somatosensory system in the peripheral or central nervous system…. The etiopathogenesis of classical trigeminal neuralgia is attributable to pathological blood vessel-nerve contact in the trigeminal nerve root entry zone to the brain stem. The typical pain symptoms are characterized by sudden stabbing pain attacks. …. The neuropathic mechanism of posttraumatic trigeminal neuropathy originates from nerve damage, which leads to peripheral and central sensitization with lowering of the pain threshold and multiple somatosensory disorders. The prophylaxis consists of avoidance of excessive acute and long-lasting pain stimuli. Against the background of the biopsychosocial pain model, the treatment of posttraumatic trigeminal neuropathy necessitates a multimodal, interdisciplinary concept."

Thimineur M, De Ridder D. 2007.  C2 area neurostimulation: a surgical treatment for fibromyalgia.  Pain Med. 8(8):639-646.  “C2 area scalp stimulation may diminish pain and related symptoms in patients with FM.”

Thoma P, Drämel N, Grothe M, et al. Impaired pain processing at a brainstem level is involved in maladaptive neuroplasticity in patients with chronic complex regional pain syndrome. Int J Mol Sci. 2022 Dec 6;23(23):15368. "This is the first study to reveal altered nBR habituation as a pathophysiological mechanism and potential diagnostic biomarker in CRPS."

Thomas CH. 2010. Spinal cord mechanisms of chronic pain and clinical implications. Curr Pain Headache Rep. 14(3):213-220. “In chronic pain states, painful stimuli trigger afferent fibers in the dorsal horn to release neuropeptides and neurotransmitters. These events induce multiple inflammatory and neuropathic processes in the spinal cord dorsal horn, and trigger modification and plasticity of local neural circuits. As a result, ongoing noxious signals to the brain are amplified and prolonged, a phenomenon known as central sensitization.”

Thomas HV, Stimpson NJ, Weightman AL et al. 2006.  Systematic review of multi-symptom conditions in Gulf War veterans.  Psychol Med. 36(6):735-747.  “Studies were included if they compared the prevalence of chronic fatigue syndrome, multiple chemical sensitivity, CDC-defined chronic multi-symptom illness, fibromyalgia, or symptoms of either fatigue or numbness and tingling…”  “The results support the hypothesis that deployment to the Gulf War is associated with greater reporting of multi-symptom conditions.”

Thomas K, Shankar H. 2013. Targeting myofascial taut bands by ultrasound. Curr Pain Headache Rep. 17(7):349. "Myofascial pain syndrome (MPS) is a frequent diagnosis in chronic pain and is characterized by tender, taut bands known as trigger points. The trigger points are painful areas in skeletal muscle that are associated with a palpable nodule within a taut band of muscle fibers. Despite the prevalence of myofascial pain syndrome, diagnosis is based on clinical criteria alone. A growing body of evidence that suggests that taut bands are readily visualized under ultrasound-guided exam, especially when results are correlated with elastography, multidimensional imaging, and physical exam findings such as local twitch response."

Thomas M., Sing H., Belenky G., Holcomb H., Mayberg H., Dannals R., Wagner H., Thorne D., Popp K., Rowland L., Welsh A., Balwinski S., Redmond D. 2000. Neural basis of alertness and cognitive performance impairments during sleepiness. I. Effects of 24 h of sleep deprivation on waking human regional brain activity. J Sleep Res 9(4):335-352. Sleep deprivation can cause dysfunction in the brain, primarily in the thalamus.  Short-term sleep deprivation produces global decreases in brain activity and dsyfunction in higher-order cognitive processes.

Thomas RJ, Terzano MG, Parrino L et al. 2004.  Obstructive sleep-disordered breathing with a dominant cyclic alternating pattern — a recognizable polysomnographic variant with practical clinical implications.  Sleep 27(2):229-234.  “This variant of sleep apnea may reflect a dominant component of respiratory instability and periodic breathing coupled with upper-airway obstruction.  Besides positive airway pressure, measures to treat periodic breathing may be required.

Thomas, S. A. and R. D. Palmiter 1997b. Impaired maternal behavior in mice lacking norepinephrine and epinephrine. Cell 91(5):583-592.

Thomas, S.P., 2000. A phenomenologic study of chronic pain. West J Nurs Res 22(6):683-99.  This paper called chronic nonmalignant pain "a force or monster that cannot be tamed", in which "time seemed to stop; the future was unfathomable".

Thomason HC 3^rd, Bos GD, Renner JB. 2001.  Calcifying tendinitis of the gluteus maximus.  Am J Orthop. 30(10):757-758.

Thompson DP, Antcliff D, Woby SR. 2017. Symptoms of chronic fatigue syndrome/myalgic encephalopathy are not determined by activity pacing when measured by the chronic pain coping inventory. Physiotherapy. [Aug 4 Epub ahead of print] "Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) is a chronic illness which can cause significant fatigue, pain and disability…. No significant associations were observed between activity pacing and levels of pain, disability or fatigue. Likewise, changes in pacing were not significantly associated with changes in pain, disability or fatigue following treatment."

Thompson EN, Usichenko T. 2018. Pain in the hand caused by a previously undescribed mechanism with possible relevance for understanding regional pain. Scand J Pain. [Jun 30 Epub ahead of print] "A previously undescribed mechanism of pain in the ulnar side of the hand was observed in a series of four patients. All were found to have a sensitive point in the first interspace of the hand and possible entrapment of a terminal branch of ulnar nerve piercing the fascia in the first interphalangeal webspace was suggested.... The location of possible nerve entrapment corresponds with an acupuncture point LI4 and may additionally represent a previously undescribed myofascial trigger point." [One is reminded that TrPs can occur anywhere in the issue, and that Travell and Simons describe the "x" marks as a good place to start looking. It is a good thing to note new TrP locations, and describe referral pain and symptoms. Travell and Simons built a great foundation and we need to build on that, as these authors have done. DJS]

Thompson HD, Tang S, Jarrell JF. Temporal Summation in Chronic Pelvic Pain. J Obstet Gynaecol Can. 2019 Dec 24. [Epub ahead of print] "Women with chronic pelvic pain and allodynia show significant worsening of pain with successive strokes of a cotton-tip applicator, thus indicates that wind-up and central sensitization are present in women with chronic pelvic pain and allodynia. Identification of summation is further evidence of neuroplasticity, which is helpful in innovative therapies for chronic pelvic pain."

Thompson JM. 2012. Exercise in muscle pain disorders. PM R. 4(11):889-893. "Muscle pain disorders range from local or regional (myofascial pain) to widespread (fibromyalgia). Many people with muscle pain have decreased fitness. Exercise intolerance is a common feature as well, and yet exercise plays an important role in the treatment of muscle pain disorders. Results of studies have shown repeatedly, via multiple modes and methods of delivery, that exercise is at least as effective as the best pharmacologic treatments. An understanding by clinicians and their patients of the unique benefits of a carefully crafted exercise program is one step in the successful management of these often frustrating muscle pain disorders." Mayo School of Graduate Medical Education

Thompson JM, Luedtke CA, Oh TH. 2010. Direct medical costs in patients with fibromyalgia: Cost of illness and impact of a brief multidisciplinary treatment program. Am J Phys Med Rehabil. [Oct 21 Epub ahead of print]. "Patients with clinically diagnosed fibromyalgia incur direct medical costs about twice that of their matched controls. This increased cost is related to the severity of their symptoms as measured by the Fibromyalgia Impact Questionnaire and was not impacted by participation in a brief cognitive behaviorally based fibromyalgia treatment program."

Thornton EW, Sykes KS, Tang WK. 2004.  Health benefits of T'ai Chi exercise: improved balance and blood pressure in middle-aged women.  Health Promot Int 19(1):33-38.  “Elderly T'ai chi practitioners attained the same level of balance control performance as did young, healthy subjects when standing under reduced or conflicting somatosensory, visual, and vestibular conditions."

Tietjen GE, Brandes JL, Peterlin BL et al. 2009.  Allodynia in migraine: association with comorbid pain conditions.  Headache. 49(9):1333-1344.  “Symptoms of CA (cutaneous allodynia) in migraine were associated with current anxiety, depression, and several chronic pain conditions.  A graded relationship was observed between number of allodynic symptoms and the number of pain conditions, even after adjusting for confounding factors.  This study also presents the novel association of CA symptoms with younger age of migraine onset, and with cigarette smoking, in addition to confirming several previously reported findings.”

Tiidus PM. 2010. Skeletal muscle damage and repair: classic paradigms and recent developments. J Musculoskel Pain. 18(4):396-402. This article explains the processes involved in muscle damage and repair, including muscle swelling, delayed onset muscle soreness, secondary injury related to the inflammatory response, and effects of sex hormones (and the loss of same on the aging), NSAIDS, and the arachidonic cascade on muscle repair. For example, NSAIDS may reduce the rate of post-injury repair, and estrogens and testosterone may enhance muscle recovery in multiple ways. The latter can be of significance to those of older years.

Tiihonen, M., M. Partinen and S. Narvanen. 1993. The severity of obstructive sleep apnea is associated with insulin resistance. J Sleep Res 2(1):56-61.

Tikiz C, Muezzinoglu T, Pirildar T et al. 2005.  Sexual dysfunction in female subjects with fibromyalgia.  J Urol. 174(2):620-623.  “Female patients with FM have distinct sexual dysfunction compared with healthy controls and coexistent MD has no additional negative effect on sexual function.  Thus, female subjects with FM should be evaluated in terms of sexual function to provide better quality of life.”

Till SR, Nakamura R, Schrepf A, et al. Approach to diagnosis and management of chronic pelvic pain in women: Incorporating chronic overlapping pain conditions in assessment and management. Obstet Gynecol Clin North Am. 2022 Jun;49(2):219-239." Chronic overlapping pain conditions (COPCs) are a specified group of chronic pain conditions that commonly co-occur in patients…. Management should include treatment of peripheral pain generators as well as co-occurring psychological conditions and central sensitization when present."

Timmerman GM, Calfa NA, Stuifbergen AK. 2013. Correlates of body mass index in women with fibromyalgia. Orthop Nurs. 32(2):113-119. "The findings support a growing body of evidence that excess weight is negatively related to quality of life and pain in women with FMS."

Ting TV, Hashkes PJ, Schikler K et al. 2012. Pediatr Rheumatol Online J. 10(1):16. The role of benign joint hypermobility in the pain experience in Juvenile Fibromyalgia: an observational study. "Juvenile Fibromyalgia (JFM) is characterized by chronic widespread musculoskeletal pain and approximately 40% of children and adolescents with JFM also suffer from benign joint hypermobility (HM)....The presence of HM among adolescent patients with JFM appears to be associated with enhanced physiologic pain sensitivity, but not self-report of clinical pain. Further examination of the mechanisms for increased pain sensitivity associated with HM, especially in adolescents with widespread pain conditions such as JFM is warranted."

Tishler, M., Smorodin, T., Vanzina-Amit, M., et al. 2003. Fibromyalgia in diabetes mellitus.  Rheumatol Int [***epub ahead of print].  “Fibromyalgia is a common finding in patients with types 1 and 2 diabetes, and its prevalence could be related to control of the disease.  As with other diabetes complications, FM might be prevented by improved control of blood glucose levels.”

To WT, James E, Ost J, Hart J Jr. et al. 2017. Differential effects of bifrontal and occipital nerve stimulation on pain and fatigue using transcranial direct current stimulation in fibromyalgia patients. J Neural Transm (Vienna). [Mar 20 Epub ahead of print.] "Our results show that repeated sessions of C2 tDCS (C2 area of occipital nerve, transcranial direct current stimulation) significantly improved pain, but not fatigue, in fibromyalgia patients, whereas repeated sessions of DLPFC (dorsolateral prefrontal cortex) tDCS significantly improved pain as well as fatigue. This study shows that eight sessions of tDCS targeting the DLPFC have a more general relief in fibromyalgia patients than when targeting the C2 area, suggesting that stimulating different targets with eight sessions of tDCS can lead to benefits on different symptom dimensions of fibromyalgia."

Tobbackx Y, Meeus M, Wauters L. 2012. Does acupuncture activate endogenous analgesia in chronic whiplash-associated disorders? A randomized crossover trial. Eur J Pain. [Sep 11 Epub ahead of print]. "It was shown that one session of acupuncture treatment results in acute improvements in pressure pain sensitivity in the neck and calf of patients with chronic WAD. Acupuncture had no effect on conditioned pain modulation or temporal summation of pressure pain. Both acupuncture and relaxation appear to be well-tolerated treatments for people with chronic WAD. These findings suggest that acupuncture treatment activates endogenous analgesia in patients with chronic WAD."

Toda K. 2014. Central Sensitization Pain Should be Included in (Central) Neuropathic Pain. Pain Physician. 17(6):E783. Free Article

Toda K. 2007.  The prevalence of fibromyalgia in Japanese workers.  Scand J Rheumatol. 36(2):140-144.  “FM is a common musculoskeletal disorder among Japanese adult workers, especially among female workers.”

Toda K, Harada T, Ishizaki F et al. 2006.  Parkinson disease patient with fibromyalgia: a case report.  Parkinsonism Relat Disord. [Jul 5 Epub ahead of print].  This report indicates that pain in Parkinson’s disease patients may be from other sources, including FMS.  [The pain could also be due to myofascial TrPs. DJS]

Todisco T, Todisco C, Bruni L et al. 2004.  Chin stimulation: a trigger point for provoking acute hiccups.  Respiration. 71(1):104.

Togha M, Bahrpeyma F, Jafari M et al. A sonographic comparison of the effect of dry needling and ischemic compression on the active trigger point of the sternocleidomastoid muscle associated with cervicogenic headache: A randomized trial. J Back Musculoskelet Rehabil. 2019 Nov 21. [Epub ahead of print] Based on the data, it may be concluded that some MTrP biomechanical features such as stiffness may influence the produced headache symptoms."

Toljan K, Vrooman B. 2018. Low-Dose Naltrexone (LDN)-Review of therapeutic utilization. Med Sci (Basel). 6(4). "Naltrexone and naloxone are classical opioid antagonists. In substantially lower than standard doses, they exert different pharmacodynamics. Low-dose naltrexone (LDN), considered in a daily dose of 1 to 5 mg, has been shown to reduce glial inflammatory response by modulating Toll-like receptor 4 signaling in addition to systemically upregulating endogenous opioid signaling by transient opioid-receptor blockade. Clinical reports of LDN have demonstrated possible benefits in diseases such as fibromyalgia, Crohn's disease, multiple sclerosis, complex-regional pain syndrome, Hailey-Hailey disease, and cancer....A dosing range between 1 μg and 1 mg comprises very low-dose naltrexone (VLDN), which has primarily been used as an experimental adjunct treatment for boosting tolerability of opioid-weaning methadone taper. In general, all of the low-dose features regarding naltrexone and naloxone have been only recently and still scarcely scientifically evaluated."

Tomori Z, Szaboova E, Donic V. 1999. Interaction of sleep apnoea syndrome with various diseases. Bratisl Lek Listy. 100(2):80-84. When sleep apnea co-exists with other conditions, these conditions can interact, and can even produce life-threatening situations. "The paper illustrates on several examples the development of pathological signs of SDB concerning practically all medical branches and at the same time demonstrating the multidisciplinary character of sleep medicine".

Toms J. 2012. [Updated view of fibromyalgia]. Cas Lek Cesk. 151(9):415-419 [Czech]. "Fibromyalgia is a chronic syndrome characterized by dysfunction of pain processing and regulation....The absence of objective diagnostic tests often results in delayed diagnosis and patient fluctuation among a number of specialists with uncertainty and fear of a serious disease. The treatment is based on the individually adjusted and multidisciplinary approach to the patient, combining pharmacological and non-pharmacological therapy."

Torgrimson-Ojerio B, Dieckmann NF, Avery S et al. 2014. Preliminary evidence of a blunted anti-inflammatory response to exhaustive exercise in fibromyalgia. J Neuroimmunol. 277(1-2):160-167. "Exercise intolerance, as evidenced by a worsening of pain, fatigue, and stiffness after novel exertion, is a key feature of fibromyalgia (FM). In this pilot study, we investigate whether; insufficient muscle repair processes and impaired anti-inflammatory mechanisms result in an exaggerated pro-inflammatory cytokine response to exhaustive exercise, and consequently a worsening of muscle pain, stiffness and fatigue in the days post-exercise. We measured changes in muscle pain and tenderness, fatigue, stiffness, and serum levels of neuroendocrine and inflammatory cytokine markers in 20 women with FM and 16 healthy controls (HCs) before and after exhaustive treadmill exercise. Compared to HCs, FM participants failed to mount the expected anti-inflammatory response to exercise and experienced a worsening of symptoms post-exercise. However, changes in post-exertional symptoms were not mediated by post-exertional changes in pro-inflammatory cytokine levels. Implications of these findings are discussed." Free Article

Toriyama T, Horiuchi T, Hongo K. 2017. Characterization of migraineurs presenting interictal widespread pressure hyperalgesia identified using a tender point count: a cross-sectional study. J Headache Pain. 18(1):117. People with migraines have hypersensitivity throughout the body both during and between migraines. "Migraine is classified as a central sensitivity syndrome, typified by fibromyalgia showing widespread pressure hyperalgesia determined by a tender point.... Interictal widespread pressure hyperalgesia was common (42%) in the episodic migraineurs and was associated with younger age at onset, female gender, and higher frequency of headache, but not duration of migraine illness. Presence of interictal widespread pressure hyperalgesia is assumed to be an indicator of genetic susceptibility to migraine attacks. We expect that a tender point count, as an alternative to quantitative sensory testing, will become useful as a diagnostic indicator of interictal hyperalgesia in migraineurs to predict susceptibility to migraine attacks and to permit tailored treatment." Free Article

Torma LM, Houck GM, Wagnild GM et al. 2012. Growing Old with Fibromyalgia: Factors That Predict Physical Function. Nurs Res. 62(1):16-24. "Resilience, a novel variable in fibromyalgia research, was a unique predictor of physical function. Further research is needed to learn more about the relationships between resilience, fibromyalgia impact, and the aging process."

Tornero-Caballero MC, Salom-Moreno J, Cigarrn-Mendez M et al. 2016. Muscle trigger points and pressure pain sensitivity maps of the feet in women with fibromyalgia syndrome. Pain Med. [Jun 1 Epub ahead of print.] This study found that the average number of active trigger points on the feet of women with fibromyalgia who had painful feet was 5 ± 1.5, with no latent trigger points. Women with FM who had no foot pain had on average 2.2 latent trigger points, and healthy women without FM had on average 1.8 latent trigger points. "The presence of foot pain in women with FMS is high. The referred pain elicited by active TrPs in the foot muscles reproduced the symptoms in these patients. FMS women suffering foot pain showed higher pressure hypersensitivity in the plantar region than those FMS women without pain."

Torres Lacomba M, Mayoral del Moral O, Coperias Zazo JL et al. 2010. Incidence of myofascial pain syndrome in breast cancer surgery: a prospective study. Clin J Pain. 26(4):320-325. “Pain after breast cancer therapy is a recognized complication found to have an adverse impact on patient's quality of life, increasing psychosocial distress.....The objective of this study was to assess the incidence of myofascial pain syndrome prospectively 12 months after breast cancer surgery....Each participant was assessed preoperatively, postoperatively between day 3 and day 5, and at 1, 3, 6, and 12 months after surgery. A physical therapist, expert in the diagnosis of myofascial pain syndrome, performed follow-up assessments. Pain descriptions by the patients and pain pattern drawings in body forms guided the physical examination. The patients were not given any information concerning myofascial pain or other muscle pain syndromes....One year follow-up was completed by 116 women. Of these, 52 women developed myofascial pain syndrome.... CONCLUSION: Myofascial pain syndrome is a common source of pain in women undergoing breast cancer surgery that includes axillary lymph node dissection at least during the first year after surgery. Myofascial pain syndrome is one potential cause of chronic pain in breast cancer survivors who have undergone this kind of surgery.”

Torres M, Mayoral del Moral O, Yuste MJ et al. 2007.  Prevalence of myofascial pain syndrome in breast cancer.  J Musculoskel Pain 15 (Supp 13):29 item 47.  [Myopain 2007 Poster]  “The prevalence of regional MPS in breast cancer suggests that it may be an important cause of pain following cancer treatment such as surgery, radiotherapy, chemotherapy or hormonal therapy.”

Torresani C, Bellafiore S, De Panfilis G. 2009.  Chronic urticaria is usually associated with fibromyalgia syndrome.  Acta Derm Venereol. 89(4):389-392.  “A total of 126 patients with chronic urticaria were investigated for fibromyalgia syndrome.  The corresponding proportion for 50 control dermatological patients was 16%, which is higher than previously published data for the Italian general population (2.2%).  It is possible that dysfunction cutaneous nerve fibers of patients with fibromyalgia syndrome may release neuropeptides, which, in turn, may induce dermal microvessel dilatation and plasma extravasation.  Furthermore, some neuropeptides may favor mast cell degranulation, which stimulates nerve endings, thus providing positive feedback.  Chronic urticaria may thus be viewed in many patients, as a consequence of fibromyalgia syndrome; in fact, skin neuropathy (fibromyalgia syndrome) may trigger neurogenic skin inflammation (chronic urticaria).”

Torstensson T, Butler S, Lindgren A et al. 2015. Referred Pain Patterns Provoked on Intra-Pelvic Structures among Women with and without Chronic Pelvic Pain: A Descriptive Study. PLoS One. 10(3):e0119542. "Referred pain patterns provoked from intra-pelvic landmarks in women with CPP are consistent with sclerotomal sensory innervation. Magnification of referred pain patterns indicates allodynia and central sensitization. The results suggest that pain mapping can be used to evaluate and confirm the pain experience among women with CPP and contribute to diagnosis."

Toto BJ. 1993.  Chiropractic correction of congenital muscular torticollis.  J Manipulative Physiol Ther. 16(8):556-559.  “Treatments included chiropractic manipulation, trigger point therapy, specific stretches, pillow positioning and exercises.  Excellent results were obtained.  Conclusion: Suggests that chiropractic intervention is a viable treatment option for congenital muscular torticollis.  Further studies should be performed to compare the effectiveness of other treatment options.”

Tough EA, White AR, Richards SH et al. 2010. Myofascial trigger point needling for whiplash associated pain - A feasibility study. Man Ther. [Jun 24 Epub ahead of print]. Forty-one patients with recent whiplash injury were tested in this study to see if phase III study specific needling therapy of myofascial TrPs was warranted. It is, and is being planned.

Toussaint LL, Whipple MO, Vincent A. 2015. Post-traumatic stress disorder symptoms may explain poor mental health in patients with fibromyalgia. J Health Psychol. [Oct 20 Epub ahead of print.] This study from the Mayo Clinic found: "Fibromyalgia patients had greater symptoms of post-traumatic stress disorder and mental health than controls. Patient-control differences in mental health symptoms were fully or partially mediated by differences in post-traumatic stress disorder symptoms. Healthcare providers should understand the role of managing trauma symptoms may be one strategy for improving mental health."

Townsley P, Ravenscroft A, Bedforth N. 2011. Ultrasound-guided spinal accessory nerve blockade in the diagnosis and management of trapezius muscle-related myofascial pain. Anaesthesia. [Mar 18 Epub ahead of print]. "We report the first description of ultrasound-guided spinal accessory nerve blockade using single-shot and subsequently continuous infusion (via a perineural catheter) local anesthetic techniques, for the diagnosis and treatment of myofascial pain affecting the trapezius muscle.... We have demonstrated that the spinal accessory nerve is identifiable in the posterior triangle of the neck and can be blocked successfully using ultrasound guidance. This technique can aid the diagnosis and treatment of myofascial pain originating from the trapezius muscle."

Tozzi P. 2014. Does fascia hold memories? J Bodyw Move Ther. 18(2):259-265. "Many bodyworkers, at some point in their practice, have experienced phenomena that may be interpreted as representing a release of memory traces when working on dysfunctional tissues. This feeling may have been accompanied by some type of sensory experience, for the therapist and/or the patient. In some cases, early traumatic experiences may be recalled. When this happens, the potency of the memory may be erased or eased, along with restoration of tissue function. Hence the questions: can memories be held in the fascia? And are these memories accessible during manual fascial work?" "…it is suggested that a possibility may exist that manual therapy might affect various forms of memory, producing profound tissue changes from subatomic to global effects." [This fascinating editorial mentions some of the possible mechanisms of cellular memory. DJS]

Trakada G, Chrousos G, Pejovic S et al. 2007. Sleep apnea and its association with the stress system, inflammation, insulin resistance and visceral obesity. Sleep Med Clin. 2(2):251-261. "Obstructive sleep apnea (OSA) is a chronic condition characterized by repetitive collapse of the upper airway during sleep leading to significant hypoxemia and recurrent arousals from sleep. OSA is associated with considerable morbidity and mortality. Four percent of adult men and two percent of adult women in general population random samples meet the current clinical and polysomnographic criteria for the diagnosis of sleep apnea. Obesity is the most important reversible risk factor for OSA. In this article, the authors review knowledge accumulated during the last 10 years about sleep apnea and its association with the stress system, inflammation, insulin resistance and visceral obesity." Free Article [There is good info here, including how lack of deep sleep can affect the HPA axis—and HPA axis disruption is often found in FM. It explains some of the interactive diagnoses of sleep apnea, the stress response system, insulin resistance., and obesity. DJS]

Trampas A, Kitsios A, Sykaras E et al. 2010. Clinical massage and modified Proprioceptive Neuromuscular Facilitation stretching in males with latent myofascial trigger points. Phys Ther Sport. 11(3):91-98.

Trampas A, Mpeneka A, Malliou V et al. 2014. Immediate Effects of Core Stability Exercises and Clinical Massage on Dynamic Balance Performance of Patients with Chronic Specific Low Back Pain. J Sport Rehabil. [Dec 4 Epub ahead of print.] This study from Greece found: "CS (core stability) exercises immediately increase the PPT (pressure pain threshold) of active MTrPs (myofascial trigger points) in physically active adults with clinical instability of the lumbar spine and chronic myofascial pain syndrome. When MTrP therapy is added, side-to-side asymmetries in dynamic balance are minimized."

Tran MT, Arendt-Nielsen L, Kupers R et al. 2012. Multiple chemical sensitivity: On the scent of central sensitization. Int J Hyg Environ Health. [Apr 7 Epub ahead of print]. "Increased capsaicin-induced secondary punctate hyperalgesia was demonstrated in MCS patients without comorbid, overlapping disorders, suggesting facilitated central sensitization in MCS."

Travell J. 1981.  Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia.  Arch Phys Med Rehabil. 62(3):100-106.  “A case report describes in detail the treatment of a patient who, for 13 years, had suffered from a medically enigmatic, intense right facial pain with severe dysfunction and who is now pain-free, with a full schedule of unrestricted activities 23 years later.”  [One cannot help but grieve for the patient’s 13 years lost to needless intense pain. DJS]

Travell JG. 1977. A trigger point for hiccup.  J Am Osteopath Assoc. 77(4):308-312.  This TrP is found in the uvula, and can be treated by stimulation with the end of a cold spoon.  [Spray with appropriate anesthetic or application of oral anesthetic can often work as well.  DJS]

Treede RD, Rief W, Barke A et al. 2019. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 160(1):19-27. "Chronic pain is a major source of suffering. It interferes with daily functioning and often is accompanied by distress. Yet, in the International Classification of Diseases, chronic pain diagnoses are not represented systematically. The lack of appropriate codes renders accurate epidemiological investigations difficult and impedes health policy decisions regarding chronic pain such as adequate financing of access to multimodal pain management. In cooperation with the WHO, an IASP Working Group has developed a classification system that is applicable in a wide range of contexts, including pain medicine, primary care, and low-resource environments. Chronic pain is defined as pain that persists or recurs for more than 3 months. In chronic pain syndromes, pain can be the sole or a leading complaint and requires special treatment and care. In conditions such as fibromyalgia or nonspecific low-back pain, chronic pain may be conceived as a disease in its own right; in our proposal, we call this subgroup "chronic primary pain." In 6 other subgroups, pain is secondary to an underlying disease: chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic posttraumatic and postsurgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain. These conditions are summarized as "chronic secondary pain" where pain may at least initially be conceived as a symptom. Implementation of these codes in the upcoming 11th edition of International Classification of Diseases will lead to improved classification and diagnostic coding, thereby advancing the recognition of chronic pain as a health condition in its own right."

Treleaven J. 2017. Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. J Orthop Sports Phys Ther. 16:1-25. [Epub ahead of print] "There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances and altered balance, eye, and head movement control following neck trauma, especially in those with persistent symptoms…. In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits. Once adequately assessed, appropriate tailored management should be implemented."

Treleaven J, Takasaki H, Grip H. 2019. Altered trunk head coordination in those with persistent neck pain. Musculoskelet Sci Pract. 39:45-50. "The results of the study suggest that neck pain subjects have difficulty moving their trunk independently of their head. They are less able to keep the head still while moving the trunk and perform the tasks more slowly. These findings might be related to altered reflex activity of the cervico-collic reflex and sensorimotor control. Further research is required."

Tremblay A, Pelletier C, Doucet E et al.  2004.  Thermogenesis and weight loss in obese individuals: a primary association with organochlorine pollution.  Int. Jour Obesity 28(7):936-939.  Many toxic chemicals can be stored in fat.  Weight loss may release toxic chemicals that slow and otherwise affect the body’s metabolism, contributing to feelings of malaise and difficulty losing weight. 

Tremolaterra F, Gallotta S, Morra Y et al. 2014. The severity of irritable bowel syndrome or the presence of fibromyalgia influencing the perception of visceral and somatic stimuli. BMC Gastroenterol. 14(1):182. "Mild and severe IBS patients without FMS demonstrated a significantly lower somatic perception cumulative score than severe IBS patients with FMS at active site. Conversely only severe IBS patients without FMS had significantly lower visceral thresholds for discomfort than mild IBS patients and severe IBS patients with FMS." Free Article

Trendafilova T, Adhikari K, Schmid AB, et al. Sodium-calcium exchanger-3 regulates pain "wind-up": From human psychophysics to spinal mechanisms. Neuron. Jun 10;S0896-6273(22)00458-5. 2022. "Repeated application of noxious stimuli leads to a progressively increased pain perception; this temporal summation is enhanced in and predictive of clinical pain disorders. Its electrophysiological correlate is "wind-up," in which dorsal horn spinal neurons increase their response to repeated nociceptor stimulation…. Our study highlights Ca2+ efflux as a pathway underlying temporal summation and persistent pain, which may be amenable to therapeutic targeting."

Trender W, Hellyer PJ, Killingley B, et al. 2024. Changes in memory and cognition during the SARS-CoV-2 human challenge study. EClinicalMedicine. 2024 Sep 21;76:102842. "Patient-reported outcomes and cross-sectional evidence show an association between COVID-19 and persistent cognitive problems…. These results support larger cross sectional findings indicating that mild Wildtype SARS-CoV-2 infection can be followed by small changes in cognition and memory that persist for at least a year…. The main differences in scores were seen in memory and executive function tasks (including working memory, attention and problem solving….Differences in scores between groups were seen up to one year after infection, with the uninfected group performing slightly better on tasks overall. The researchers note that the observed differences were small and that none of the volunteers reported prolonged cognitive symptoms. They also highlight limitations of the study, including the small sample size and that the majority of participants were white males…"

Triana AM, Salmi J, Hayward NMEA, et al. 2024. Longitudinal single-subject neuroimaging study reveals effects of daily environmental, physiological, and lifestyle factors on functional brain connectivity. PLoS Biol. 2024 Oct 8;22(10):e3002797. "From Neuroscience News: A unique study tracked one person's brain activity and behavior over five months, revealing how daily habits like sleep, exercise, and mood can impact the brain for days.… The study found that our brains do not respond to daily life in immediate, isolated bursts. Instead, brain activity evolves in response to sleep patterns, physical activity, mood, and respiration rate over many days. This suggests that even a workout or a restless night from last week could still affect your brain — and therefore your attention, cognition and memory — well into next week."

Trinanes Y, Gonzalez-Villar A, Gomez-Perretta C et al. 2014. Suicidality in chronic pain: Predictors of suicidal ideation in fibromyalgia. Pain Pract. [Apr 1 Epub ahead of print.] "The presence of suicidal ideation in FM patients is closely related to comorbid depression, anxiety and to a higher impact of the disease in daily life."

Trofimovitch D, Baumrucker SJ. 2019. Pharmacology Update: Low-Dose Naltrexone as a Possible Nonopioid Modality for Some Chronic, Nonmalignant Pain Syndromes. Am J Hosp Palliat Care. Mar 27:1049909119838974. "Naltrexone is a reversible competitive antagonist at μ-opioid and κ-opioid receptors, which when used at standard doses of 50 to 150 mg was initially intended for use in opioid and alcohol use disorders. However, it was discovered that its use in low doses follows alternate pharmacodynamic pathways with various effects. When used in doses of 1 to 5 mg it acts as a glial modulator with a neuroprotective effect via inhibition of microglial activation. It binds to Toll-like receptor 4 and acts as an antagonist, therefore inhibiting the downstream cellular signaling pathways that ultimately lead to pro-inflammatory cytokines, therefore reducing inflammatory response. Its other mode of action involves transient opioid receptor blockade ensuing from low-dose use which upregulates opioid signaling resulting in increased levels of endogenous opioid production, known as opioid rebound effect. Low dose naltrexone has gained popularity as an off-label treatment of several autoimmune diseases including multiple sclerosis and inflammatory bowel disease, as well as chronic pain disorders including fibromyalgia, complex regional pain syndrome, and diabetic neuropathy. Low-dose naltrexone (LDN) may also have utility in improving mood disorders and the potential to enhance the quality of life. This article will therefore propose the potential off-label use of LDN in management of nonmalignant pain in the palliative medicine setting."

Trouvin AP, Perrot S2.New concepts of pain. Best Pract Res Clin Rheumatol. 2019 Jun;33(3):101415. "Active research is being conducted on musculoskeletal pain, and recent concepts will help clinicians and researchers to develop better approaches: -the new pain taxonomy recently has been modified with a third descriptor with the concept of nociplastic pain. -the latest International Classification of Diseases (ICD-11) includes an IASP task force that developed a new classification system for pain. In this new classification, one can differentiate primary musculoskeletal pain including fibromyalgia and low back pain and secondary musculoskeletal pain related to specific etiologies. -the concept of central sensitization in inflammatory rheumatic diseases is increasingly discussed. In these conditions, even with very active biological treatment, almost a third of patients are still complaining of persisting pain. These persisting pain states under adequate treatment, without any sign of inflammation, led researchers to look for evidence of central sensitization states".

Trucharte A, Leon L, Castillo-Parra G et al. 2020. Emotional regulation processes: influence on pain and disability in fibromyalgia patients. Clin Exp Rheumatol. [Jan 9 Epub ahead of print] "Results showed that although FM patients do not differ in terms of the attention paid to their emotional states, FM patients had greater difficulties in the emotional regulation process. In addition, emotional rejection and interference are two variables that influence the pain severity and disability…. FM patients need to be trained in strategies for regulating their emotions, in order to achieve a reduction in negative mood states, as well as their impact in pain and disability."

Truini A, Tinelli E, Gerardi MC et al. 2016. Abnormal resting state functional connectivity of the periaqueductal grey in patients with fibromyalgia. Clin Exp Rheumatol. 34(2 Suppl 96):129-133. "Our fMRI study showing abnormal resting state functional connectivity of the PAG (periaqueductal gray) suggests that patients with fibromyalgia have an endogenous pain modulatory system dysfunction, possibly causing an impaired descending pain inhibition. This abnormal PAG functioning might underlay the chronic pain these patients suffer from."

Trujillo, K. A. and H. Akil. 1994. Inhibition of opiate tolerance by non-competitiveN-methyl-D-aspartate receptor antagonists. Brain Res 633(1-2):178-88.

Tsai CT, Hsieh LF, Kuan TS et al. 2009.  Injection in the cervical facet joint for shoulder pain with myofascial trigger points in the upper trapezius muscle.  Orthopedics. 32(8).  “This study demonstrates that intra-articular or peri-articular injection into the cervical facet joint region can effectively inactivate the upper trapezius myofascial trigger point secondary to the facet lesion.”  [Trigger points have perpetuating factors.  If the TrPs return in spite of appropriate treatment, the perpetuating factor must be identified and brought under control.  In this case, the perpetuating factor was a facet joint problem. DJS]

Tsai CT, Hsieh LF, Kuan TS et al. 2009.  Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle.  Am J Phys Med Rehabil. [Apr 28 Epub ahead of print].  “This study demonstrated the remote effectiveness of dry needling.  Dry needling of a distal myofascial trigger point can provide a remote effect to reduce the irritability of a proximal myofascial trigger point.”

Tsai PF, Edison JL, Wang CH, et al. 2024. Characteristics of patients with myofascial pain syndrome of the low back. Sci Rep.2024 May 24;14(1):11912. "Pain pressure threshold, physical function, and other self-reported outcomes were measured. Significant differences were found in Group 1 (Active), 2 (Latent), 3 (Atypical, no twitching but with spontaneous pain), and 4 (Atypical, no twitching and no spontaneous pain) of participants in the number of MTrPs, current pain, and worst pain in the past 24 h…. There were interaction effects between spontaneous pain and twitching response on reports of physical function, current pain, and worst pain…. Participants in Group 3 reported lower levels of physical function, and higher levels of current pain and worst pain compared to those in Group 4. Participants in Group 1 and 2 had similar levels of physical function, current pain, and worst pain. The number of MTrPs is most closely associated with the level of pain. Spontaneous pain report seems to be a decisive factor associated with poor physical function; however, twitching response is not."

Tsai P, Edison J, Wang C, et al. 2024. Myofascial trigger point (MTrP) size and elasticity properties can be used to differentiate characteristics of MTrPs in lower back skeletal muscle. Sci Rep. 2024 Mar 30;14(1):7562. "Here we develop ultrasound (US) based diagnostic metrics that can be used to distinguish the biophysical properties of MTrPs, and show how those metrics can be used by clinicians during patient diagnosis and treatment. We highlight the advantages and limitations of previous US-based approaches that utilize elasticity theory. To overcome these previous limitations, we use a hierarchical approach to distinguish MTrP properties by patients' reported pain and clinician measured palpation. We show how US-based measurements can characterize MTrPs with this approach. We demonstrate that MTrPs tend to be smaller, stiffer, and deeper in the muscle tissue for patients with pain compared to patients without pain. We provide evidence that more than one MTrP within a single US-image field increases the stiffness of neighboring MTrPs. Finally, we highlight a combination of metrics (depth, thickness, and stiffness) that can be used by clinicians to evaluate individual MTrPs in combination with standard clinical assessments."

Tsay A, Allen TJ, Proske U et al. 2015. Sensing the body in chronic pain: A review of psychophysical studies implicating altered body representation. Neurosci Biobehav Rev. 52:221-232. "There is growing evidence that chronic pain conditions can have an associated central pathology, involving both cortical reorganization and an incongruence between expected and actual sensory-motor feedback. While such findings are primarily driven by the recent proliferation of neuroimaging studies, the psychophysical tasks that complement those investigations have received little attention. In this review, we discuss the literature that involves the subjective appraisal of body representation in patients with chronic pain. We do so by examining three broad sensory systems that form the foundations of the sense of physical self in patients with common chronic pain disorders: (i) reweighting of proprioceptive information; (ii) altered sensitivity to exteroceptive stimuli; and, (iii) disturbed interoceptive awareness of the state of the body. Such findings present compelling evidence for a multisensory and multimodal approach to therapies for chronic pain disorders." [This review combines the exteroceptive, interoceptive and proprioceptive networks, and it is fascinating to see these together. Trigger points may be the link to these dysfunctional fields in chronic pain patients. Trigger points are known to cause proprioception dysfunction, and that is well-documented. I have observed many fibromyalgia patients have improved interoception (sense of what is going on in the interior of the body) with trigger point work, but that hasn't been studied. I hope it will be. DJS]

Tseng CH, Chen JH, Wang YC et al. 2016. Increased risk of stroke in patients with fibromyalgia: A population-based cohort study. Medicine (Baltimore). 95(8):e2860. "This is the first investigation associating FM with an increased risk of stroke development. The outcomes imply that FM is a significant risk factor for stroke and that patients with FM, particularly younger patients, require close attention and rigorous measures for preventing stroke."

Tseng SC, Cheng AM2, Fu Y. 2017. Retrospective study to identify trigeminal-cervical ocular referred pain as a new causative entity of ocular pain. J Pain Res. 10:1747-1754. "A retrospective study of 1,680 patients seen during 2002-2010 was performed in an ocular surface specialty center to identify patients with or without TC (trigeminal-cervical) pain defined as ocular pain with ipsilateral trigger points located at the occipital region. Patients with refractory TC pain despite topical anesthetics and conventional treatments received interventional injection to each trigger point…. Injection at the trigger points achieved complete or partial pain resolution with a low recurrence rate in 43 of 45 (96%) patients with TC pain….TC pain… can indeed be differentiated from other ocular pain by the referral character so that one may avoid mislabeling it as undetermined or as a reason to unnecessarily overtreat concomitant ocular diseases." Free Article

Tsigos C, Chrousos G. 2002. Hypothalamic-pituitary- adrenal axis, neuroendocrine factors and stress.  J Psychosom Res 53(4):865.  When the stress response system is disrupted, many other hormones and informational substances can be affected, including sex hormones, growth hormone and thyroid hormone.

Tsilioni I, Russell IJ, Stewart JM et al. 2016. Substance P, Hemokinin-1, CRH, TNF and IL-6 are increased in serum of patients with fibromyalgia syndrome and may serve both as biomarkers and targets for treatment. J Pharmacol Exp Ther. [Jan 13 Epub ahead of print.] "Our results indicate that neuro-inflammation may contribute to the symptoms of FMS patients, especially since we had previously shown that CRH and SP are known to stimulate IL-6 and TNF release from mast cells. Treatment directed at preventing the secretion on antagonizing these elevated neuro-immune markers may be useful in the management of FMS patients." Free Article

Tsuchie H, Miyakoshi N, Kasukawa Y et al. 2013. High prevalence of abdominal aortic aneurysm in patients with chronic low back pain. Tohoku J Exp Med. 230(2):83-86. "The prevalence of LBP (low back pain) is high in AAA (abdominal aortic aneurysm) patients, and doctors who treat chronic LBP should be aware of AAA as a potential cause of LBP." [This study is included here to alert readers that abdominal aortic aneurysm is common in low back pain patients and must be assessed and can mimic symptoms of spinal or myofascial pain. DJS]

Tu CH, Lin CL, Yang ST et al. 2020. Hormonal contraceptive treatment may reduce the risk of fibromyalgia in women with dysmenorrhea: A cohort study. J Pers Med. Dec 14;10(4):280. "After controlling confounding variables, results revealed that women with dysmenorrhea have a significantly higher risk of fibromyalgia than women without dysmenorrhea. However, only treatment of dysmenorrhea with hormonal contraceptives reduce the risk of fibromyalgia. These results indicated that dysmenorrhea may be a risk factor of fibromyalgia, whereas personalized medicine for treatment of dysmenorrhea may be the key to reduce the risk of fibromyalgia." [Anything that irritates the central nervous system sufficiently can produce the central sensitization of FM. Reducing pain reduces the chance of developing FM. DJS]

Tu CH, Niddam DM, Yeh TC et al. 2013. Menstrual pain is associated with rapid structural alterations in the brain. Pain. [May 18 Epub ahead of print]. "Dysmenorrhea is the most prevalent gynecological disorder for women in the childbearing age. Dysmenorrhea is associated with central sensitization and functional and structural changes in the brain. Our recent brain morphometry study disclosed that dysmenorrhea is associated with trait-related abnormal gray matter (GM) changes even in the absence of menstrual pain, indicating that the adolescent brain is vulnerable to menstrual pain. Here we report rapid state-related brain morphological changes, i.e. between pain and pain-free states, in dysmenorrhea. We used T1-weighted anatomical magnetic resonance imaging to investigate regional GM volume changes between menstruation and peri-ovulatory phases, in 32 dysmenorrhea subjects and 32 age- and menstrual cycle-matched asymptomatic controls. An optimized voxel-based morphometry analysis was conducted to disclose the possible state-related regional GM volume changes across different menstrual phases. A correlation analysis was also conducted between GM differences and the current menstrual pain experience in the dysmenorrhea group. Compared to the peri-ovulatory phase, the dysmenorrhea subjects revealed greater hypertrophic GM changes than controls during the menstruation phase in regions involved in pain modulation, generation of the affective experience and regulation of endocrine function while atrophic GM changes were found in regions associated with pain transmission. Volume changes in regions involved in regulation of endocrine function and pain transmission correlated with the menstrual pain experience scores. Our results demonstrated that short-lasting cyclic menstrual pain is associated not only with trait-related but also rapid state-related structural alterations in the brain. Considering the high prevalence rate of menstrual pain, these findings mandate a great demand to revisit dysmenorrhea regarding its impact on the brain and other clinical pain conditions."

Tu Y, Wang J, Xiong F, et al. Cortical abnormalities in patients with fibromyalgia: a pilot study of surface-based morphometry analysis. Pain Med. 2022 Jul 26;Online ahead of print." Our findings provide evidence of neuroanatomical aberrations in FM patients, which may provide insight into the neuropathology of FM."

Tubbs AS, Fernandez FJ, Grandner MA, et al. The mind after midnight: Nocturnal wakefulness, behavioral dysregulation, and psychopathology. Front Netw Physiol. 2022; Epub 2022 Mar 3. "Sufficient sleep with minimal interruption during the circadian/biological night supports daytime cognition and emotional regulation. Conversely, disrupted sleep involving significant nocturnal wakefulness leads to cognitive and behavioral dysregulation. Most studies to-date have examined how fragmented or insufficient sleep affects next-day functioning, but recent work highlights changes in cognition and behavior that occur when someone is awake during the night. This review summarizes the evidence for day-night alterations in maladaptive behaviors, including suicide, violent crime, and substance use, and examines how mood, reward processing, and executive function differ during nocturnal wakefulness. Based on this evidence, we propose the Mind after Midnight hypothesis in which attentional biases, negative affect, altered reward processing, and prefrontal disinhibition interact to promote behavioral dysregulation and psychiatric disorders.

Tuckey B, Srbely J, Rigney G, Vythilingam M, et al. Impaired lymphatic drainage and interstitial inflammatory stasis in chronic musculoskeletal and idiopathic pain syndromes: Exploring a novel mechanism. Front Pain Res (Lausanne). 2021 Aug 23;2:691740. "A normal functioning lymphatic pump mechanism and unimpaired venous drainage are required for the body to remove inflammatory mediators from the extracellular compartment. Impaired vascular perfusion and/or lymphatic drainage may result in the accumulation of inflammatory substances in the interstitium, creating continuous nociceptor activation and related pathophysiological states including central sensitization and neuroinflammation. We hypothesize that following trauma and/or immune responses, inflammatory mediators may become entrapped in the recently discovered interstitial, pre-lymphatic pathways and/or initial lymphatic vessels. The ensuing interstitial inflammatory stasis is a pathophysiological state, created by specific pro-inflammatory cytokine secretion including tumor necrosis factor alpha, interleukin 6, and interleukin 1b. These cytokines can disable the local lymphatic pump mechanism, impair vascular perfusion via sympathetic activation and… may lead to additional stasis through direct fascial compression of pre-lymphatic pathways. These mechanisms, when combined with other known pathophysiological processes, enable us to describe a persistent feed-forward loop capable of creating and maintaining chronic pain syndromes. The potential for concomitant visceral and/or vascular dysfunction, initiated and maintained by the same feed-forward inflammatory mechanism, is also described." [Myofascial pain syndrome is not well understood, although it is one of the most common causes of musculoskeletal pain. It is usually brief in duration, but in some cases, becomes chronic and may spread. Chronic MPS can be associated with symptoms beyond the myofascia, including fatigue, sleep dysfunctions, and gut pain. This paper explains how a process beginning with elevated pro-inflammatory cytokines might promote changes in the extracellular area leading to a state of inflammatory interstitial stasis. How this state could lead to the formation of myofascial trigger points and eventually, to central sensitization, is explained by this hypothesis. DJS]

Tugnet N, Williams R. 2012. "My bones hurt." An unusual cause of fibromyalgia syndrome. J Musculoskel Pain 20(3):208-221. This excellent case report documents fibromyalgia caused by multiple bony hemangiomatosis. [This is a good reminder that when the central nervous system is sensitized, it has been sensitized by something. One must look for the cause. DJS]

Tuncer, T., B. Butun, M. Arman, A. Akyokus and A. Doseyen. 1997. Primary fibromyalgia and allergy. Clin Rheumatol 16(1):9-12.

Tuncer M, Çoban K, Erbek SS, et al. Audiovestibular dysfunction in patients with fibromyalgia syndrome. J Int Adv Otol. 2021 Jul;17(4):348-352. "Pure-tone hearing thresholds of right and left ears were found to be decreased in fibromyalgia patients compared to controls.... Middle ear resonance frequency values were significantly decreased in patients with fibromyalgia syndrome compared to controls.... The values for signal-to-noise ratios were higher in controls than in the FMS patients. The difference was significant for 1000, 2000, and 4000 Hz...."

Tuo KS, Cheng YY, Kao CL. 2006.  Vestibular rehabilitation in a patient with whiplash-associated disorders.  J Chin Med Assoc. 69(12):591-595.   Prompt comprehensive rehabilitation, including TrP injection, coordination and vestibular rehab, may successfully treat some cases of whiplash syndrome

Turk DC, Adams LM. 2016. Using a biopsychosocial perspective in the treatment of fibromyalgia patients. Pain Manag. [Jun 15 Epub ahead of print.] "Fibromyalgia (FM) is a complex illness that manifests in different ways across individuals. Given that there are currently no known cures for FM, like treatment for other chronic diseases, interventions focus on learning strategies to alleviate symptom severity, to cope with and manage residual symptoms of the illness and to maximize health-related quality of life despite symptoms. In this article, we highlight the need for providers to adopt a biopsychosocial perspective for understanding and addressing patients with FM, noting that biological, psychosocial and behavioral factors function interdependently to affect a person's experience and adaptation. A cognitive-behavioral approach, which incorporates a biopsychosocial perspective, is detailed, along with specific treatment considerations for helping patients with FM manage their symptoms."

Turkoglu G, Selvi Y.The relationship between chronotype, sleep disturbance, severity of fibromyalgia, and quality of life in patients with fibromyalgia. Chronobiol Int. 2019 Nov 5:1-14. "The severity of FM symptoms, chronotype preferences, and QoL was evaluated using the Fibromyalgia Impact Questionnaire (FIQ), Morningness-Eveningness Questionnaire (MEQ), and World Health Organization Questionnaire on Quality of Life: Short Form (WHOQOL-BREF).... Our results indicated that eveningness preference was directly related to increased FM symptom severity and poorer QoL. Based on these findings, neglecting to take chronotype preference into account may not result in optimal response to standard treatment for some patients with FM."

Turkyilmaz AK, Kurt EE, Capkin E et al. 2012. Assessment of neuropathic pain in patients with fibromyalgia syndrome: A pilot study. J Musculoskel Pain. 20(3):170-176. [This study indicated that many patients with fibromyalgia have neuropathic pain syndromes that are associated with pain severity. Since many if not all fibromyalgia patients also have myofascial trigger points, and trigger points can cause nerve entrapment and these symptoms, it is to be hoped that future studies will include co-existing trigger points as a possible cause of these symptoms. DJS]

Turo D, Otto P, Gebreab T et al. 2013. Shear wave elastography for characterizing muscle tissue in myofascial pain syndrome. J Acoust Soc Am. 133(5):3358. "Myofascial pain syndrome (MPS) affects 85% of chronic pain sufferers in a specialty pain center. Neck and low-back are commonly affected by MPS. Myofascial trigger points (MTrPs) are characteristic findings of MPS and are palpable tender nodules in the muscles of symptomatic subjects. Mechanical characterization of MTrPs and surrounding tissue can offer important insight about the pathophysiology of the MPS, which is currently poorly understood. In this study, we propose an inexpensive technique, based on ultrasound shear wave elastography, to objectively measure mechanical properties of MTrPs and surrounding tissue in the upper trapezius. In an ongoing clinical study, we recruited 34 subjects: 12 healthy controls, 10 with not spontaneously painful MTrPs (latent) and 12 with symptomatic chronic neck pain (>3 months) and active (spontaneously painful) MTrPs. Shear wave elastography was performed on the upper trapezius of all subjects using the Ultrasonix RP system and an external vibrator. Voigt's model was used to estimate shear modulus G and viscosity µ of the interrogated tissue. Preliminary analysis demonstrates that symptomatic muscle tissue in subjects with neck pain is stiffer …compared to muscle in control subjects… and that active MTrPs are more viscous …than surrounding tissue…. Latent MTrPs …and surrounding tissue … are more viscous than normal tissue …."

Turo D, Otto P, Hossain M et al. 2015. Novel use of ultrasound elastography to quantify muscle tissue changes after dry needling of myofascial trigger points in patients with chronic myofascial pain. J Ultrasound Med. [Oct 21 Epub ahead of print.] "Objectives: To compare a mechanical heterogeneity index derived from ultrasound vibration elastography with physical findings before and after dry-needling treatment of spontaneously painful active myofascial trigger points in the upper trapezius muscle…. Conclusion: The mechanical heterogeneity index identifies changes in muscle tissue properties that correlate with changes in the myofascial trigger point status after dry needling."

Turo D, Otto P, Shah JP et al. 2013. Ultrasonic characterization of the upper trapezius muscle in patients with chronic neck pain. Ultrason Imaging. 35(2):173-187. "Localization, diagnosis, and clinical outcome measures of painful MTrPs (myofascial trigger points) can be improved by objectively characterizing and quantitatively measuring their properties. The goal of this study was to evaluate whether ultrasound imaging and elastography can differentiate symptomatic (active) MTrPs from normal muscle.....results suggest that active MTrPs have more homogeneous texture and heterogeneous stiffness when compared with normal, unaffected muscle. Our methods enabled us to improve the imaging contrast between suspected MTrPs and surrounding muscle. Our results indicate that in subjects with chronic neck pain and active MTrPs, the abnormalities are not confined to discrete isolated nodules but instead affect the milieu of the muscle surrounding palpable MTrPs. With further refinement, ultrasound imaging can be a promising objective method for characterizing soft tissue abnormalities associated with active MTrPs and elucidating the role of MTrPs in the pathophysiology of MPS."

Turo D, Otto P, Shah JP et al. 2012. Ultrasonic tissue characterization of the upper trapezius muscle in patients with myofascial pain syndrome. Conf Proc IEEE Eng Med Biol Soc. 2012:4386-4389. Myofascial trigger points (MTrPs) are palpable, tender nodules in skeletal muscle that produce symptomatic referred pain when palpated…. Objective characterization and quantitative measurement of the properties of MTrPs can improve their localization and diagnosis, as well as lead to clinical outcome measures. MTrPs associated with soft tissue neck pain are often found in the upper trapezius muscle. We have previously demonstrated that MTrPs can be visualized using ultrasound imaging. The goal of this study was to evaluate whether texture-based image analysis can differentiate structural heterogeneity of symptomatic MTrPs and normal muscle.

Tutoglu A, Boyaci A, Koca I et al. 2014. Quality of life, depression, and sexual dysfunction in spouses of female patients with fibromyalgia. Rheumatol Int. [Jan 9 Epub ahead of print.] "Being a spouse of a patient with fibromyalgia might significantly interfere with quality of life and lead to a high rate of sexual dysfunction. Spouses of patients with fibromyalgia might also be investigated for sexual dysfunction and quality of life. Treatment programs for this group should be considered."

Tutuncu M, Ertem DH, Soysal A. 2020. Prevalence and impact of myofascial pain syndrome in relapsing-remitting multiple sclerosis and the effects of local anesthetic injections for short-term treatment. Mult Scler Relat Disord. Sep 26;46:102528. "Patients with active myofascial trigger points received local anesthetics blocks monthly and attended at least 4 follow-up appointments…. The primary outcome was a 50 % reduction in pain intensity….The results of this study support that MFPS can be experienced in patients with RRMS. Local anesthetic injections for trigger points may be an effective, tolerable, and inexpensive treatment for this patient group and contribute to significant reductions in pain severity scores and increase the quality of life." [It is important to remember that TrPs can add to the symptom burden of many chronic conditions. DJS]

Tuunainen E, Poe D, Jantti P et al. 2011. Presbyequilibrium in the oldest olds, a combination of vestibular, oculomotor and postural deficits. Aging Clin Exp Res. [Mar 29 Epub ahead of print]. "Progressive loss of balance in the aged, or "presbyequilibrium," is a complex and incompletely understood process involving vestibular, oculomotor, visual acuity, proprioception, motor, organ system and metabolic weaknesses and disorders. These factors provide some potential basis for streamlining the diagnostic evaluation and aiding in planning for effective therapy. In the oldest olds, these problems are magnified, raising the need for additional expertise in their care that could be met by training specialized health care staff." [This study makes a good point. It would be interesting to include myofascial TrPs, a common cause of balance dysfunction, as part of this process. DJS]

Tuzun EH, Gıldır S, Angın E et al. 2017. Effectiveness of dry needling versus a classical physiotherapy program in patients with chronic low-back pain: a single-blind, randomized, controlled trial. J Phys Ther Sci. 29(9):1502-1509. This study from Cypress treated patients with low-back pain due to lumbar disc hernia. "The control group performed a home exercise program in addition to hot pack, TENS, and ultrasound applications….These results suggest that dry needling can be an effective treatment for reducing pain, number of trigger points, sensitivity, and kinesiophobia in patients with chronic low-back pain caused by lumbar disc hernia." Free Article

Tverdohleb T, Dinc B, Knezevic I et al. 2016. The role of cytochrome P450 pharmacogenomics in chronic non-cancer pain patients. Expert Opin Drug Metab Toxicol. 1-9. "Pharmacogenomics is the field that studies an individualized treatment approach for patients' medication regimen that can impact drug safety, productivity, and personalized health care. Pharmacogenomics characterizes the genetic differences in metabolic pathways which can affect a patient's individual responses to drug treatments…. The various responses to pharmacological agents are mainly determined by the different types of genetic variants of the CYP450. CYP2D6 polymorphism is well known for its variation in the metabolism of drugs from many therapeutic arenas, including some analgesic drugs such as codeine, hydromorphone, oxycodone and tramadol. Allele combinations determine the phenotypic expression, characterized as either: extensive metabolizer, intermediate metabolizer, ultra-rapid metabolizer and poor metabolizer…. The Human Genome Project (HGP) revolutionized the future of medicine and the way health care providers approach individualized patient treatment, and chronic pain management is one of those areas. The key findings in the literature appear to be related to the CYP2D6 expression and its high polymorphism influencing the metabolism of opioid medications, and the impact of that on the patient's therapeutic outcome thus exemplifying the importance of genetic testing for CYP2D6 in the process of physician therapeutic decision making.

Tzeng NS, Chung CH, Liu FC et al. 2018. Fibromyalgia and risk of dementia - A nationwide, population-based, cohort study. Am J Med Sci. 355(2):153-161. This nationwide (Taiwan) matched-cohort population-based study aimed to investigate the association between fibromyalgia and the risk of developing dementia, and to clarify the association between fibromyalgia and dementia....A total of 41,612 patients of age (approximately) 50 years with newly diagnosed fibromyalgia between January 1 and December 31, 2000 were selected from the National Health Insurance Research Database of Taiwan, along with 124,836 controls matched for sex and age. After adjusting for any confounding factors, Fine and Gray competing risk analysis was used to compare the risk of developing dementia during the 10 years of follow-up....Fibromyalgia was associated with increased risk of all types of dementia in this study....The study subjects with fibromyalgia had a 2.77-fold risk of dementia in comparison to the control group. Therefore, further studies are needed to elucidate the underlying mechanisms of the association between fibromyalgia and the risk of dementia.

Ucar IC, Esen F, Turhan SA, et al. 2021. Corneal neuropathic pain in irritable bowel syndrome: clinical findings and in vivo corneal confocal microscopy. Graefes Arch Clin Exp Ophthalmol. Jun 29. Online ahead of print."Ocular discomfort is a common symptom in central sensitization syndromes. The aim of this study was to evaluate ocular surface discomfort and related corneal changes in patients with irritable bowel syndrome…. Patients with IBS have increased dry eye-associated ocular surface complaints and nerve fiber loss in corneal subbasal nerve plexus. IBS should be remembered in the differential diagnosis, when there is discordance between the level of ocular surface discomfort and dry eye disease associated corneal findings."

Uceyler N, Buchholz HG, Kewenig S et al. 2020.Cortical binding potential of opioid receptors in patients with fibromyalgia syndrome and reduced systemic Interleukin-4 levels - A pilot study Front Neurosci. May 19;14:512. "We investigated cerebral opioid receptor binding potential in patients with fibromyalgia syndrome (FMS) using positron-emission-tomography (PET) and correlated our results with patients' systemic interleukin-4 (IL-4) gene expression…. Neurological examination was normal in all FMS patients. Reduced opioid receptor binding was found in mid cingulate cortex compared to healthy controls (p < 0.005). Interestingly, three patients with high systemic IL-4 gene expression had increased opioid receptor binding in the fronto-basal cortex compared to those with low IL-4 gene expression (p < 0.005). Conclusion: Our data give further evidence for a reduction in cortical opioid receptor availability in FMS patients as another potential central nervous system contributor to pain in FMS."

Uceyler N, Zeller D, Kahn AK et al. 2013. Small fibre pathology in patients with fibromyalgia syndrome. Brain. [Epub Mar 9]This case control study of 25 patients investigated shape and function of small nerve fibers through punch biopsies of the upper thigh and lower leg, plus patient neurological assessment. FM patients had increased neuropathic findings in questionnaires. Compared with healthy controls and patients with depression, FM patients had impaired small fiber function with increased cold and warm sensation thresholds and increased reaction to touch/pain stimuli. There were a smaller number of unmyelinated nerve fiber bundles in the skin of FM patients compared to the others, although mylinated nerve fibers were equal in all groups. This study indicates that pain in FM has a neuropathic nature.[These patients were not screened for co-existing myofascial trigger points and related microcirculation abnormalities and nerve entrapment. DJS]

Uemoto L, Antonio C Garcia M, Vinicius D et al. 2013. Laser therapy and needling in myofascial trigger point deactivation. J Oral Sci. 55(2):175-181. Twenty-one women patients with bilateral masseter TrPs were divided into groups to receive either laser therapy, needling with local anesthetic or no treatment (control). The laser and needling groups experienced a significant decrease of pain by visual analogue scale. A significant decrease in pressure pain threshold was experienced by the local anesthetic needling group only. This study indicates that four sessions of needling with 2% lidocaine without vasoconstrictor, with intervals between 48 and 72 hours between treatments, or laser therapy at a dose of 4 J/cm2, effectively deactivated the TrPs.

Uemoto L, Nascimento de Azevedo R, Almeida Alfaya T et al. 2013. Myofascial trigger point therapy: laser therapy and dry needling. Curr Pain Headache Rep. 17(9):357. "The aim of the present review is to discuss two forms of treatment for myofascial pain: laser therapy and dry needling. Although studies have reported the deactivation of myofascial trigger points with these two methods, clinical trials demonstrating their efficacy are scarce. The literature reports greater efficacy with the use of laser over dry needling. It has been suggested that improvements in microcirculation through the administration of laser therapy may favor the supply of oxygen to the cells under conditions of hypoxia and help remove the waste products of cell metabolism, thereby breaking the vicious cycle of pain, muscle spasm and further pain. While laser therapy is the method of choice for patients with a fear of needles and healthcare professionals inexperienced with the dry needling technique, further controlled studies are still needed to prove the greater efficacy of this method."

Ullrich A, Hauer J, Farin E. 2014. Communication preferences in patients with fibromyalgia syndrome: descriptive results and patient characteristics as predictors. Patient Prefer Adherence. 8:135-145. "Communication with patients with fibromyalgia syndrome (FMS) is often considered difficult. The primary objective of this explorative study was to describe the communication preferences of FMS patients in comparison with other chronic diseases, and the secondary objective was to identify patient-related predictors of those communication preferences….Health care providers who communicate with FMS patients should employ an open and patient-centered communication style, and affective communication components should be adapted to accommodate each patient."

Uludag M, Kaparov A, Sari H et al. 2011. Osteopoikilosis associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles. J Back Musculoskel Rehabil. 24(4):257-261. "The sclerosing bone dysplasia known as osteopoikilosis can be associated with fibromyalgia and trigger points." [This is another case of interactive diagnoses. DJS]

Ulusoy EK. 2020. Effects of comorbid fibromyalgia syndrome on activities of daily living in multiple sclerosis patients. Arq Neuropsiquiatr. 78(9):556-560. "These results indicate that increased frequency of comorbid fibromyalgia syndrome in multiple sclerosis causes worsening in activities of daily living and quality of life, delayed diagnosis, disability progression, and increased admission rates."

Ulusoy MO, Kal A, Işik-Ulusoy S et al. 2018. Choroidal thickness in patients with fibromyalgia and correlation with disease severity. Indian J Ophthalmol. 66(3):428-432. "The results of this study demonstrated that choroidal thickness decreases in patients with FM and correlated with disease activity. This choroidal change might be related with the alterations in autonomic nervous system functioning. Further studies are needed to evaluate the etiopathologic relationship between choroidal thickness and FM.

Umeda M, Corbin LW, Maluf KS. 2014. Examination of contraction-induced muscle pain as a behavioral correlate of physical activity in women with and without fibromyalgia. Disabil Rehabil. [Nov 20 Epub ahead of print.] "Women with FM exhibit augmented muscle pain during isometric contractions and reduced physical activity than healthy controls. Furthermore, contraction-induced muscle pain is inversely associated with physical activity levels. These observations suggest that augmented muscle pain may serve as a behavioral correlate of reduced physical activity in women with FM….Women with fibromyalgia experience a greater intensity of localized muscle pain in a contracting muscle compared to healthy women. The intensity of pain during muscle contraction is inversely associated with the amount of physical activity in women with and without fibromyalgia. Future studies should determine whether exercise adherence can be improved by considering the relationship between contraction-induced muscle pain and participation in routine physical activity." [Due to the lack of data, it is not known whether this result is due to co-existing trigger points or is actually due to FM. DJS]

Umeda M, Corbin LW, Maluf KS. 2013. Pain mediates the association between physical activity and the impact of fibromyalgia on daily function. Clin Rheumatol. [Sep 13 Epub ahead of print]. "This study quantified the association between recreational physical activity and daily function in women with fibromyalgia, and determined if this association is mediated by symptoms of pain, depression, or body mass….These results indicate that the intensity of musculoskeletal pain, rather than depressive symptoms or body mass, mediates the association between physical activity and daily function among women with fibromyalgia." This study shows that pain itself is the driving factor determining the amount of activity and function in FM women, and it is not the "sedentary nature" or depression that drives the pain.

Unverzagt C, Berglund K, Thomas JJ. 2015. Dry needling for myofascial trigger point pain: A clinical commentary. Int J Sports Phys Ther. 10(3):402-418. "Sports and orthopedic physical therapists have long used a multitude of techniques in order to address pain and dysfunction associated with myofascial trigger points. One technique in particular has recently received overwhelming attention: trigger point dry needling (DN). Despite its efficacy and low risk, questions remain as to its effectiveness, safety, and whether the technique is within the scope of practice of physical therapists. Therefore, the purpose of this clinical commentary is to summarize the current literature related to the associated mechanisms of action of DN, the safety of DN, as well as to discuss relevant scope of practice concerns." Free PMC Article

Urata M, Fukuno H, Nomura M et al. 2006.  Gastric motility and autonomic activity during obstructive sleep apnea.  Aliment Pharmacol Ther. 24 Suppl 4:132-140.  “The present study suggested that, in addition to decreased pressure on the pleural cavity, factors affecting the development of RE might include abnormal gastric motility, low oxygen, and increased sympathetic nervous activity during sleep apnea.”

Uremovic M, Cvijetic S, Pasic MD et al. 2007. Impairment of proprioception after whiplash injury.  Coll Antropol. 31(3):823-827.  “…subject with recent cervical spine injury have incorrect perception of their head position.  Therefore, their rehabilitation should include the correction of proprioception and head coordination.”  [Assessment for associated MTPs in the head and neck, which may adversely affect priprioception, as well as restrict range of motion and cause other symptoms, should be done promptly, and treatment continued until the MTPs are resolved to avoid chronicity if possible. DJS]

Urits I, Burshtein A, Sharma M et al. 2019. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. Mar 11;23(3):23. "Low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain. Annually, the prevalence of low back pain in the general US adult population is 10-30%, and the lifetime prevalence of US adults is as high as 65-80%..... Patient history, physical exam, and diagnostic testing are important components to accurate diagnosis and identification of patient pathophysiology. Etiologies of low back pain include myofascial pain, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, and failed back surgery. In chronic back pain patients, a multidisciplinary, logical approach to treatment is most effective and can include multimodal medical, psychological, physical, and interventional approaches."

Urresti F, Perez LG, Cueco RT. 2007.  Effectiveness of deep dry needling of trigger points in lateral pterigoid muscle.  J Musculoskel Pain 15 (Supp 13):40 item 69.  [Myopain 2007 Poster]  “LPTM (lateral pterygoid muscle) MTP appears to be a common cause of temporomandibular pain.”

Urschitz, MS, Guenther, A, Eggebrecht, E et al.  Snoring, intermittent hypoxia and academic performance in primary school children.  Am J Resp Crit Care Med 168:464-468.  Habitual snoring is significantly associated with poor academic performance.

Ursini F, Ciaffi J, Mancarella L, et al. 2021. Fibromyalgia: a new facet of the post-COVID-19 syndrome spectrum? Results from a web-based survey. RMD Open. Aug;7(3):e001735. "Postacute COVID-19 syndrome (PACS) is an emerging entity characterised by a large array of manifestations, including musculoskeletal complaints, fatigue and cognitive or sleep disturbances. Since similar symptoms are present also in patients with fibromyalgia (FM), we decided to perform a web-based cross-sectional survey aimed at investigating the prevalence and predictors of FM in patients who recovered from COVID-19…. Our study suggests that up to 30% of patients with PACS may satisfy criteria for fibromyalgia (FM)…. Our data suggest that clinical features of FM are common in patients who recovered from COVID-19 and that obesity and male gender affect the risk of developing post-COVID-19 FM."

Usai Satta P, Oppia F, Cabras F. 2017. Overview of pathophysiological features of GERD. Minerva Gastroenterol Dietol. [Mar 1 Epub ahead of print.] "Gastro-esophageal reflux disease (GERD) is a very prevalent condition and has a high impact on the quality of life. Nevertheless, pathophysiology is complex and multifactorial. Several mechanisms have been proposed: decreased salivation, decreased lower esophageal sphincter pressure resting tone, presence of hiatal hernia, increased number of transient lower esophageal sphincter relaxations, increased acid, and pepsin secretion, duodeno-gastro-esophageal reflux of bile acids and trypsin. Other factors contributing to the pathophysiology of GERD include poor esophageal clearance, delayed gastric emptying and impaired mucosal defensive factors. Esophageal mucosa integrity is impaired both in patients with erosive esophagitis also in regions macroscopically normal and in NERD patients. Patients with functional heartburn have instead a normal mucosal integrity. The mechanisms underlying extra-esophageal GERD are instead more controversial. Reflux symptoms could be caused by oesophageal hypersensitivity as a result of visceral neural pathway dysfunction. Multiple mechanisms influence the perception of GERD symptoms, such as the acidity of the refluxate, its proximal extent, the presence of gas in the refluxate, duodeno-gastro-esophageal reflux, mucosal integrity, and peripheral and central sensitization. Furthermore several risk factors can influence the onset of GERD and its complications such as life style, obesity, genetics, pregnancy, and stress. In particular obesity is associated with complications related to longstanding reflux such as erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Understanding the pathophysiology of gastroesophageal reflux is important for future targets for therapy. Further research is necessary to improve the current knowledge of the contributing factors leading to GERD."

Usui C, Hatta K, Doi N et al. 2010. Brain perfusion in fibromyalgia patients and its differences between responders and poor responders to gabapentin. Arthritis Res Ther. 12(2):R64. “The present study revealed brain regions with significant hyperperfusion associated with the default-mode network, in addition to abnormalities in the sensory dimension of pain processing and affective-attentional areas in fibromyalgia patients. Furthermore, hyperperfusion in these areas was strongly predictive of poor response to gabapentin.”

Vachon CM, Modchalingam S, t'Hart BM et al. 2020. The effect of age on visuomotor learning processes. PLoS One. Sep 14;15(9):e0239032. "We make an explicit, cognitive strategy available to half of participants in each age group with a detailed instruction. After training, we first quantify the explicit learning elicited by instruction. Instructed older adults initially use the provided strategy slightly less than younger adults but show a similar ability to evoke it after training. This indicates that cognitive explanations for age-related decline in motor learning are limited. In contrast, training induced much larger shifts of state estimates of hand location in older adults compared to younger adults. This is not modulated by strategy instructions, and appears driven by recalibrated proprioception, which is almost twice as large in older adults, while predictions might not be updated in older adults. This means that in healthy aging, some implicit processes may be compensating for other changes to maintain motor capabilities, while others also show age-related decline. [One missing process may well be myofascial trigger points and their proprioceptive concomitants. DJS]

Vadivelu N, Hines RL. 2008.  Management of chronic pain in the elderly: focus on transdermal buprenorphine.  Clin Interv Aging. 3(3):421-430.  “The transdermal buprenorphine matrix allows for slow release of buprenorphine and damage does not produce dose dumping.  In addition, the long-acting analgesic property and relative safety profile makes it a suitable choice for the treatment of chronic pain in the elderly.  Its safe use in the presence of renal failure makes it an attractive choice for older individuals.  Recent scientific studies have shown no evidence of a ceiling dose of analgesia in man but only a ceiling effect for respiratory depression, increasing its safety profile.  It appears that transdermal buprenorphine can be used in clinical practice safely and efficaciously for treating chronic pain in the elderly.”

Vadivelu N, Lumermann L, Zhu R et al. 2016. Pain control in the presence of drug addiction. Curr Pain Headache Rep. 20(5):35. "Careful selection of medications and appropriate oversight, including drug agreements, can reduce drug-induced impairments, including sleep deficits and diminished physical, social, and sexual functioning. This review, therefore, discusses the prevalence of illicit and prescription drug addiction, the challenges of achieving optimum pain control, and the therapeutic approaches to be considered in this challenging population. More research is warranted to develop improved therapies and routes of treatments for optimum pain relief and to prevent the development of central sensitization, chronic pain, and impaired physical and social functioning in patients with drug addiction."

Vaeroy, H., A. Abrahamsen, O. Forre and E. Kass. 1989. Treatment of fibromyalgia (fibrositis syndrome): a parallel double-blind trial with carisoprodol, paracetamol and caffeine (Somadrilcomp) versus placebo. Clin Rheumatol 8(2):245-250. "…the treament combinaiton of carisoprodol, and paracetamol (acetaminophen) and caffeine are effective in the treatment of fibromyalgia."

Vafadar AK, Cote JN, Archambault PS. 2015. Sex differences in the shoulder joint position sense acuity: a cross-sectional study. BMC Musculoskelet Disord. 16:273. "The result of this study showed that shoulder position sense, as part of the neuromuscular control system, differs between men and women. This finding can help us better understand the reasons behind the higher rate of musculoskeletal disorders in women, especially in the working environments. Gender differences are not confined to hormones." Free Article

Valencia-Flores M, Cardiel MH, Santiago V et al. 2004. Prevalence and factors associated with fibromyalgia in Mexican patients with systemic lupus erythematosus.  Lupus 13(1):4-10.  “Fibromyalgia is not common in Mexican patients with SLE and has a different pattern of symptoms in RP (regional pain) and NP (no pain) patients.  These data add evidence that ethnicity can play an important role in FM manifestations.” 

Valentine TR, Kratz AL. Feasibility, reliability, and validity of ambulatory cognitive tests in fibromyalgia and matched controls. J Int Neuropsychol Soc. 2023 Feb 10;1-9. "Repeated ambulatory tests of processing speed and working memory demonstrate feasibility and reliability in FM, though evidence for construct validity is mixed. The findings demonstrate promise for future research and clinical applications of this approach to assessing cognition in FM."

Valenza MC, Rodenstein DO, Fernandez-de-las-Penas C. 2011. Consideration of sleep dysfunction in rehabilitation. J Bodyw Mov Ther. 15(3):262-267. Patients with whiplash commonly have neck pain that is contributory to sleep disturbance. There is a direct relationship between pain intensity and worsening sleep quality. It is essential to treat both the causes of the pain and the sleep dysfunction components as part of management of these patients.

Valenza MC, Valenza G, Gonzalez-Jimenez E et al. 2011. Alteration in sleep quality in patients with mechanical insidious neck pain and whiplash-associated neck pain. Am J Phys Med Rehabil. [Dec 14 Epub ahead of print]. "Sleep disturbances are a common finding in individuals with neck pain and are associated with the intensity of ongoing pain in WAD (whiplash)." Inadequate sleep quality and quantity can contribute to multi-system effects. "It seems essential to address the ongoing cycle of pain and sleep disturbances as an integral part of the treatment of patients with neck pain."

Valenzuela-Moguillansky C, Reyes-Reyes A, Gaete MI. 2017. Exteroceptive and interoceptive body-self awareness in fibromyalgia patients. Front Hum Neurosci. 11:117. "Fibromyalgia patients exhibited a higher tendency to note bodily sensations and decreased body confidence…. There was a lower tendency to actively listen to the body for insight, with higher passability ratios across the whole sample. Based on our results and building on the fear-avoidance model, we outline a proposal that highlights possible interactions between exteroceptive and interoceptive body awareness and pain. Movement based contemplative practices that target sensory-motor integration and foster non-judgmental reconnection with bodily sensations are suggested to improve body confidence, functionality, and quality of life. Free Article

Valkeinen H, Hakkinen A, Alen M et al. 2007.  Physical fitness in postmenopausal women with fibromyalgia.  Int J Sports Med. [Oct 24 Epub ahead of print].  “A lower maximal load in the aerobic test suggests the patients’ unsatisfactory ability to stand physical loading and resist overall fatigue.  Moreover, fatigue rather than pain was the main factor to decrease the quality of life in women with fibromyalgia.  Additional efforts should be addressed to strength training, when planning health promotion and rehabilitation programs in fibromyalgia.”  [These results may be suspect as there is no allowance for co-existing MTPs that could be affecting the results.  Also, strength training, if there are MTPs, will only make them worse.  You can’t strengthen a muscle that is physiologically inhibited by MTPs.  DJS]

Vallerand A, Nowak L. 2010. Chronic opioid therapy for nonmalignant pain: the patient's perspective. Part II--Barriers to chronic opioid therapy. Pain Manag Nurs. 11(2):126-131. "Limited qualitative research exists that reflects patients' perspectives regarding the stigmatization and barriers that they encounter when using this treatment option. This paper reports part II of the results of a phenomenologic study that investigated the experience of 22 adults receiving opioid therapy for chronic nonmalignant pain, with a focus on associated stigmas and barriers to treatment. Overall, the data reflected that these individuals encounter much stigma surrounding their pain management regimen, and that the routine course of maintaining that regimen is fraught with barriers. These barriers arise from family, the health care system, and society at large. Awareness of the life-enhancing benefits of opioid therapy in adults with chronic nonmalignant pain, as well as the stigma and barriers that they encounter, will enable clinicians to intervene appropriately and to act as advocates on behalf of adults using chronic opioid therapy."

Vallerand A, Nowak L. 2009. Chronic opioid therapy for nonmalignant pain: the patient's perspective. Part I--Life before and after opioid therapy. Pain Manag Nurs. 10(3):165-172. "Although opioid therapy has been shown to decrease pain intensity, improve quality of life, and enhance functioning for adults with pain, opioids are rarely used as a long-term treatment option. Limited qualitative research exists that reflects patients' perspectives regarding life with chronic nonmalignant pain. This paper reports the results of a phenomenologic study that investigated the experience of 22 adults receiving opioid therapy for chronic nonmalignant pain. Themes that emerged regarding life before and after treatment with opioid therapy are discussed in part 1 of this two-part series. Life before treatment with opioids was characterized by desperation and inability to function. Life after treatment with opioids was characterized by balancing, living a secret life, fear of losing the pain management regimen, and thankfulness for a life regained. Overall, the data reflected the fact that these individuals trade the incapacitation of chronic pain for secrecy to regain their life and improve their functional capacity and ability to perform self-care."

Vallejo M, Martinez-Martínez LA, Grijalva-Quijada S et al. 2013. Prevalence of fibromyalgia in vasovagal syncope. J Clin Rheumatol. 19(3):111-114. "Fibromyalgia was relatively frequent in these women with vasovagal syncope and could be associated with dysautonomic symptoms. Therefore, it seems important to search for dysautonomic comorbidities in patients with vasovagal syncope and/or fibromyalgia, to provide a patient-centered holistic approach, instead of the often currently used therapeutic partition."

Valouchova P, Lewit K. 2009.  Surface electromyography of abdominal and back muscles in patients with active scars.  J Bodywork Move Ther. 13(3):262-267.  Abdominal scars may significantly impair back mobility and add to clinical symptoms.   These scars and the tissue around them can often be treated successfully with manual methods, and this study gives objective data of surface electromyography to show this.  The “…muscles surrounded by active scar tissue are likely to harbour trigger points.”

Valrie CR, Bromberg MH, Palermo T et al. 2013. A systematic review of sleep in pediatric pain populations. J Dev Behav Pediatr. 34(2):120-128. "Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Health care providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed."

van Campen CMC, Rowe PC, Verheugt FWA,et al. 2020. Orthostatic stress testing in myalgic encephalomyelitis/chronic fatigue syndrome patients with or without concomitant fibromyalgia: effects on pressure pain thresholds and temporal summation. Clin Exp Rheumatol. Sep 10. Online ahead of print. "Pressure pain threshold decreased in ME/CFS patients with or without fibromyalgia after head-up tilt test (HUT), but did not change post-HUT in healthy controls. Windup pre- and post-HUT was significantly higher compared to healthy controls, but did not change from pre- to post-HUT. These results demonstrate that, like exercise, orthostatic stress can negatively influence the physiology of pain perception in ME/CFS. Furthermore, the physiology of pain perception is even more negatively influenced by concomitant fibromyalgia".

Van Cauter E, Holmback U, Knutson K et al. 2007.  Impact of sleep and sleep loss on neuroendocrine and metabolic function.  Horm Res. 67 Suppl 1:2-9.  “Laboratory studies in healthy young volunteers have shown that experimental sleep restriction is associated with a dysregulation of the neuroendocrine control of appetite consistent with increased hunger and with alterations in parameters of glucose tolerance suggestive of an increased risk of diabetes.  Epidemiologic findings in both children and adults are consistent with the laboratory data.”  Deep sleep has a significant effect on hormones.

Van Cauter E, Latta F, Nedeltcheva A et al.  2004.  Reciprocal interactions between the GH axis and sleep.  Growth Horm IGF Res. 14 Suppl A:S10-7.  “Preliminary data show decreased total sleep time and increased sleep fragmentation in GH-deficient patients as compared with normal controls.”

Van Daele DJ, McCulloch TM, Palmer PM et al. 2005.  Timing of glottic closure during swallowing: a combined electromyographic and endoscopic analysis.  Ann Otol Rhinol Laryngol. 114(6):478-487.  [This article indicates why TrPs in some of the area muscles could have some patients choking on their own saliva, “swallowing the wrong way".    In such cases, it may be wise to check the thyroarytenoid and other area muscles for TrPs.]

van de Donk T, Niesters M, Kowal MA et al. 2018. An experimental randomized study on the analgesic effects of pharmaceutical-grade cannabis in chronic pain patients with fibromyalgia. Pain. [Dec 20 Epub ahead of print] "Cannabis varieties containing THC caused a significant increase in pressure pain threshold relative to placebo… CBD inhalation increased THC plasma concentrations but diminished THC-induced analgesic effects, indicative of a synergistic pharmacokinetic but antagonistic pharmacodynamic interactions of THC and CBD. This experimental trial shows the complex behavior of inhaled cannabinoids in chronic pain patients with just small analgesic responses after a single inhalation. Further studies are needed to determine long-term treatment effects on spontaneous pain scores, THC-CBD interactions and the role of psychotropic symptoms on pain relief."

van de Glind G, de Vries M, Rodenburg R et al. 2007.  Resting muscle pain as the first clinical symptom in children carrying the MTTK A8344G mutation.  Eur J Paediatr Neurol. [Feb 9 Epub ahead of print]  “Fatigue in combination with recurrent resting muscle pain occurs frequently in the initial phase of various hereditary muscle disorders and in several autoimmune, endocrine and metabolic syndromes.  In the absence of obvious biochemical/metabolic abnormalities and in the lack of neurological symptoms, the complaints are frequently labeled as fibromyalgia or chronic fatigue syndrome.”  [We certainly need more research into genetic mitochondrial defects.  DJS]

van der Esch M, Holla JF, van der Leeden M et al. 2014. Decrease of muscle strength is associated with increase of activity limitations in early knee osteoarthritis: 3-year results from the Cohort Hip and Cohort Knee study. Arch Phys Med Rehabil. [Jun 27 Epub ahead of print.] "In patients with early knee OA, decreased muscle strength is associated with an increase in activity limitations. Our results are a step towards understanding the role of muscle weakness in the development of activity limitations in knee OA. Further, well-designed experimental studies are indicated to establish the causal role of muscle weakness in activity limitations." [Myofascial trigger points co-exist with OA, and often cause the muscle weakness and proprioceptive dysfunctions described. It would be of value to have these patients assessed for TRPs, as the symptoms might be relieved with treatment of TrPs. DJS]

VanderWeide LA, Smith SM, Trinkley KE. 2014. A systematic review of the efficacy of venlafaxine for the treatment of fibromyalgia. J Clin Pharm Ther. Oct 8. [Epub ahead of print] "Studies assessing the efficacy of venlafaxine in the treatment of fibromyalgia to date have been limited by small sample size, inconsistent venlafaxine dosing, lack of placebo control and lack of blinding. In the context of these limitations, venlafaxine appears to be at least modestly effective in treating fibromyalgia. Larger randomized controlled trials are needed to further elucidate the full benefit of venlafaxine."

Van de Ven TJ, John Hsia HL. 2012. Causes and prevention of chronic postsurgical pain. Curr Opin Crit Care [Jun 22 Epub ahead of print]. "Surgical incision invariably causes some measure of nerve damage and inflammatory response that, in most cases, heals quickly without long-term negative consequence. However, a subset of these patients go on to develop lasting neuropathic pain that is difficult to treat and, in many cases, prevents the return to normal activities of life. It remains unknown why two patients with identical surgical interventions may go on to develop completely divergent pain phenotypes or no pain at all. Aggressive, early analgesic therapy has been shown to reduce the incidence of chronic postsurgical pain (CPSP), but no specific regional anesthetic technique or systemic pharmacologic therapy has been shown to prevent CPSP....Inflammation and glial cell activation have recently been shown to be just as important in the transition from normal acute pain to pathologic chronic pain as nerve injury itself and that central sensitization may not be solely due to repetitive nociceptive firing at the time of nerve injury. This has opened a number of new therapeutic possibilities for prevention of CPSP....Here, we discuss the causes of CPSP and current useful preventive strategies in the perioperative period. We also discuss future potential disease-modifying treatments of CPSP." [Since glial cells in the spinal cord have been implicated in the development of central sensitization states such as fibromyalgia, this is of interest. Histamine levels, microcirculation, and other factors affecting TrP development may be part of the answer to this puzzle. DJS]

Van Gordon W, Shonin E, Dunn TJ et al. 2016. Meditation awareness training for the treatment of fibromyalgia syndrome: A randomized controlled trial. Br J Health Psychol. [Nov 25 Epub ahead of print.] "Meditation awareness training may be a suitable treatment for adults with FMS and appears to ameliorate FMS symptomatology and pain perception …."

Van Houdenhove B, Luyten P. 2006.  Stress, depression and fibromyalgia.  Acta Neurol Belg. 106(4):149-156.

Van Houdenhove B, Neerinckx, E, Onghena P et al. 2002. Daily hassles reported by chronic fatigue syndrome and fibromyalgia patients in tertiary care: a controlled quantitative and qualitative study.  Psychother Psychosom 71(4):207-13. Patients with Chronic Fatigue Syndrome and FM show "a higher frequency of hassles, higher emotional impact and higher fatigue, pain depression and anxiety levels than patients with RA or MS."  The cause of the hassles are "dissatisfaction with oneself, insecurity and a lack of social recognition."  "An optimal therapeutic approach of CFS and FMS should take account of this heavy psychosocial burden, which might refer to core themes of these patients' experiences."

Vanini G. 2016. Sleep deprivation and recovery sleep prior to a noxious inflammatory insult influence characteristics and duration of pain. Sleep. 39(1):133–142. "Insufficient sleep and chronic pain are public health epidemics. Sleep loss worsens pain and predicts the development of chronic pain. Whether previous, acute sleep loss and recovery sleep determine pain levels and duration remains poorly understood. This study tested whether acute sleep deprivation and recovery sleep prior to formalin injection alter post-injection pain levels and duration. The finding that acute sleep deprivation enhanced post-formalin nociception suggests that sleep loss prior to an inflammatory insult can contribute to chronic pain by increasing the propensity to develop central sensitization. Several studies are congruent with the conclusion that sleep deprivation increases cortical and thalamic excitability. Microdialysis data show state-specific changes in neurotransmitter levels within the spinal cord, and sleep deprivation causes mechanical98 and thermal hypersensitivity by altering the neurochemical milieu within spinal sensory regions. Taken together, the data reviewed above support the hypothesis that sleep deprivation can facilitate and maintain central sensitization by altering descending (cortico-spinal) and ascending mechanisms that process or modulate pain."

Van Liew C, Leon G, Neese M et al. 2018. You get used to it, or do you: symptom length predicts less fibromyalgia physical impairment, but only for those with above-average self-efficacy. Psychol Health Med. 30:1-14. "These results suggest that the effects of age and symptom duration on FMS are unique, and that self-efficacy plays a crucial role in moderating disease course (measured by symptom duration or time) in FMS."

Van Middendorp H, Lumley MA, Moerbeek M et al. 2009.  Effects of anger and anger regulation styles on pain in daily life of women with fibromyalgia: a diary study.  Eur J Pain. [Apr 16 Epub ahead of print].  “Our study suggests that anger and a general tendency to inhibit anger predicts heightened pain in the everyday life of female patients with fibromyalgia.  Psychological intervention could focus on healthy anger expression to try to mitigate the symptoms of fibromyalgia.”

Vanneste S, Ost J, Van Havenbergh T et al. 2017. Resting state electrical brain activity and connectivity in fibromyalgia. PLoS One. 12(6):e0178516. "The exact mechanism underlying fibromyalgia is unknown, but increased facilitatory modulation and/or dysfunctional descending inhibitory pathway activity are posited as possible mechanisms contributing to sensitization of the central nervous system. The primary goal of this study is to identify a fibromyalgia neural circuit that can account for these abnormalities in central pain. The second goal is to gain a better understanding of the functional connectivity between the default and the executive attention network (salience network plus dorsal lateral prefrontal cortex) in fibromyalgia. We examine neural activity associated with fibromyalgia (N = 44) and compare these with healthy controls (N = 44) using resting state source localized EEG. Our data support an important role of the pregenual anterior cingulate cortex but also suggest that the degree of activation and the degree of integration between different brain areas is important. The inhibition of the connectivity between the dorsal lateral prefrontal cortex and the posterior cingulate cortex on the pain inhibitory pathway seems to be limited by decreased functional connectivity with the pregenual anterior cingulate cortex. Our data highlight the functional dynamics of brain regions integrated in brain networks in fibromyalgia patients." Free Article [Fibromyalgia may be invisible, but we are finding more and more biochemicals that show it is physiological and central nervous system in nature. DJS]

van Oosterwijck J, Meeus M, Paul L et al. 2013. Pain physiology education improves health status and endogenous pain Inhibition in fibromyalgia: A double-blind randomized controlled trial. Clin J Pain. [Jan 30 Epub ahead of print]. "These results suggest that FM patients are able to understand and remember the complex material about pain physiology. Pain physiology education seems to be a useful component in the treatment of FM patients as it improves health status and endogenous pain inhibition in the long term."

Van Oosterwijck J, Nijs J, Meeus M et al. 2012. Evidence for central sensitization in chronic whiplash: A systematic literature review. Eur J Pain. [Sep 25 Epub ahead of print]. "It has been suggested that sensitization of the central nervous system plays an important role in the development and maintenance of chronic (pain) complaints experienced by whiplash patients. According to the PRISMA guidelines, a systematic review was performed to screen and evaluate the existing clinical evidence for the presence of central sensitization in chronic whiplash....These studies evaluated the sensitivity to different types of stimuli (mechanical, thermal, electrical). Findings suggest that although different central mechanisms seem to be involved in sustaining the pain complaints in whiplash patients, hypersensitivity of the central nervous system plays a significant role.....international guidelines for the definition, clinical recognition, assessment and treatment of central sensitization are warranted."

van Rensburg R, Meyer HP, Hitchcock SA et al. 2017. Screening for adult ADHD in patients with fibromyalgia syndrome. Pain Med. [Nov 1 Epub ahead of print] "These results indicate that the co-occurrence of adult ADHD in FMS may be highly prevalent and may also significantly impact the morbidity of FMS. Patients with FMS should be assessed for the presence of adult ADHD."

Van Ryckeghem DML, Rost S, Kissi Aet al. 2018. Task interference and distraction efficacy in patients with fibromyalgia: an experimental investigation. Pain. [Mar 6 Epub ahead of print] "Overall, task performance of FM patients was slower compared to the task performance in the healthy control group. In contrast to our hypotheses, FM patients and healthy volunteers did not differ in the magnitude of the interference effect and distraction-efficacy. In conclusion, current study provides support for contemporary theories claiming that attention modulates the experience of pain and vice versa. However, no evidence was found for an altered attentional processing of pain in fibromyalgia patients. Furthermore, results indicate that task interference and distraction-efficacy are not just two sides of the same coin."

van Uden-Kraan CF, Drossaert CH, Taal E et al. 2010. Patient-initiated online support groups: motives for initiation, extent of success and success factors. J Telemed Telecare. 16(1):30-34. “We studied the success and success factors of online support groups (OSGs) for patients, and the motives and goals of people who start such groups. We interviewed 23 webmasters of OSGs for patients with breast cancer, fibromyalgia and arthritis. The majority were women (n = 20) and most were patients (n = 21). Analysis of the interviews revealed that webmasters had altruistic and intrinsic motives for initiating an online support group. They defined success as the fulfillment of the goals they had in mind when they initiated their groups. To be able to make a group successful, decisions about its organization and management need to be coherent with these goals. Most webmasters stressed that promoting the group, keeping it alive and moderating the messages were vital success factors during the evolution stage. Management of the OSGs took up much of the webmasters' time and energy. On average webmasters were occupied with the group for 10-15 hours a week. Our study provides an overview of the pros and cons of differing decisions that have to be made when initiating an OSG.”

van Uden-Kraan CF, Drossaert CH, Taal E et al. 2008.  Empowering processes and outcomes of participation in online support groups for patients with breast cancer, arthritis, or fibromyalgia.  Qual Health Res. 18(3):405-417.  “Empowering outcomes mentioned were being better informed; feeling confident in the relationship with their physician, their treatment, and their social environment; improved acceptance of the disease; increased optimism and control; enhanced self-esteem and social well-being; and collective action.”  “...participation in online support groups can make a valuable contribution to the emergence of empowered patients.” [It is vitally important that the support groups be positive and empowering.   Negative groups that are exclusive or stressful can have an equally undermining effect on patient quality of life. DJS]

van Vliet J, Verrips A, Tieleman AA et al. 2016. No relevant excess prevalence of myotonic dystrophy type 2 in patients with suspected fibromyalgia syndrome. Neuromuscul Disord. [Apr 6 Epub ahead of print.] "Myotonic dystrophy type 2 (DM2) is a rare, autosomal dominant, multisystem disorder with proximal weakness, myotonia, pain and cataract as important symptoms." This study from the Netherlands found no greater number of DM2 patients with FM, indicating that there is no reason to test patients with FM for DM2 unless there are indications, such as excess creatine kinase, cataracts, and other members of the family with this genetic condition.

Van Wilgen CP, Dijkstra PU, Van Der Laan BF et al. 2004.  Morbidity of the neck and head and neck cancer therapy.  Head Neck 26(9):785-791.  The authors found that 46% of the post-surgery cancer patients had myofascial pain.  [This indicates that at least some of the pain, loss of range of motion and muscle weakness the patients with co-existing myofascial pain sustained could be either eliminated or minimized by adequate treatment of the myofascial component. DJS]

van Wilgen CP, Keizer D. 2012. The sensitization model to explain how chronic pain exists without tissue damage. Pain Manag Nurs. 13(1):60-65. "The interaction of nurses with chronic pain patients is often difficult. One of the reasons is that chronic pain is difficult to explain, because no obvious anatomic defect or tissue damage is present. There is now enough evidence available indicating that chronic pain syndromes such as low back pain, whiplash, and fibromyalgia share the same pathogenesis, namely, sensitization of pain modulating systems in the central nervous system. Sensitization is a neuropathic pain mechanism in which neurophysiologic changes may be as important as behavioral, psychological, and environmental mechanisms. The sensitization model provides nurses with an opportunity to explain pain as a physical cause related to changes in the nervous system. This explanation may improve the patient's motivation to discuss the importance of psychosocial factors that contribute to the maintenance of chronic pain. In this article, sensitization is described as a model that can be used for the explanation of the existence of chronic pain. The sensitization model is described using a metaphor. The sensitization model is a useful tool for nurses in their communication and education toward patients."

Van Wilgen CP, Ucles-Juarez R, Krutko D, et al. Knowledge on cause, clinical manifestation and treatment for fibromyalgia among medical doctors: A worldwide survey. Pain Pract. 2023 Dec 29. Online ahead of print. "In the current study, we conducted a worldwide survey in which we investigate whether medical doctors are familiar with the American College of Rheumatology (ACR) criteria for fibromyalgia and, if so, whether these medical doctors adhere to the clinical guidelines following evidence-based treatments…. From this study, we conclude that many medical doctors do not follow the ACR criteria; the majority has an inappropriate knowledge of causes for fibromyalgia and that a minority of treatment advice adhere to the guidelines.

Varallo G, Pitera P, Fontana JM, et al. Is whole-body cryostimulation an effective add-on treatment in individuals with fibromyalgia and obesity? A randomized controlled clinical trial. J Clin Med. 2022 Jul 26;11 (15):4324. "Pain severity, depression, and sleep disturbances are key targets for FM rehabilitation… Our findings suggest that WBC could be a promising add-on treatment to improve key aspects of FM, such as pain, depressive symptoms, disease impact and poor sleep quality."

Vargas-Alarcon G, Alvarez-Leon E, Fragoso JM et al. 2012. A SCN9A gene-encoded dorsal root ganglia sodium channel polymorphism associated with severe fibromyalgia. BMC Musculoskel Disord. 13(1):23. "A consistent line of investigation suggests that autonomic nervous system dysfunction may explain the multi-system features of fibromyalgia (FM); and that FM is a sympathetically maintained neuropathic pain syndrome....The aim of this study was to search for an association between fibromyalgia and several SCN9A sodium channels gene polymorphisms....We studied 73 Mexican women suffering from FM and 48 age-matched women who considered themselves healthy....In this ethnic group; a disabling form of FM is associated to a particular SCN9A sodium channel gene variant. These preliminary results raise the possibility that some patients with severe FM may have a dorsal root ganglia sodium channelopathy."

Vargas-Schaffer G, Nowakowsky M, Eghtesadi M et al. 2015. Ultrasound-guided trigger point injection for serratus anterior muscle pain syndrome: description of technique and case series. A Case Rep. 5(6):99-102. "Chronic chest pain is a challenge, and serratus anterior muscle pain syndrome (SAMPS) is often overlooked. We have developed an ultrasound-guided technique for infiltrating local anesthetics and steroids in patients with SAMPS. In 8 patients, the duration of chronic pain was approximately 19 months. Three months after treatment, all patients had experienced a significant reduction in pain. Infiltration for SAMPS confirms the diagnosis and provides adequate pain relief."

Varinen A, Kosunen E, Mattila K et al. 2017. The relationship between childhood adversities and fibromyalgia in the general population. J Psychosom Res. 99:137-142. "There were associations between examined adversities and fibromyalgia before and after adjustments for demographic features and depression (being afraid of a family member: odds ratio after adjustment, long-lasting financial difficulties, serious conflicts in the family; parental divorce..., serious or chronic illnesses in the family…, alcohol problems in the family…. All six enquired adversities were associated with fibromyalgia after adjustments. These findings emphasize the importance of preventing adverse childhood experiences."

Varol U, Ubeda-D'Ocasar E, Margarita Cigaran-Mendez M, et al. Understanding the psychophysiological and sensitization mechanisms behind fibromyalgia syndrome: A network analysis approach. Pain Med. 2022 Aug 12; Online ahead of print. "Current evidence suggests that fibromyalgia syndrome (FMS) involves complex underlying mechanisms….Our findings support a model where clinical sensory-related, psychological, and psycho-physical variables are connected, albeit in separate clusters, reflecting a nociplastic condition with a relevant role of sensitization. Clinical implications of the findings, such as developing treatments targeting these mechanisms, are discussed. [It is time to identify and treat the pain sources causing/maintaining central sensitization, with the understanding that different subsets of FM have different symptom sources. DJS]

Vas L, Pai R. 2019. Ultrasound-guided dry needling as a treatment for postmastectomy pain syndrome - A case series of twenty patients. Indian J Palliat Care. 25(1):93-102. "Existing interventions for postmastectomy pain syndrome (PMPS) address the neural component while overlooking a possible myofascial component…. USGDN (ultrasound-guided dry needling) reduced pain, disability, and opioid use, whereas NI (neural interventions) reduced only pain. This suggests a myofascial contribution to pain and disability in PMPS.

Vas L, Pai R, Geete D et al. 2017. Improvement in CRPS after deep dry needling suggests a role in myofascial pain. Pain Med. [Jun 19 Epub ahead of print]

Vas L, Pai R, Khandagale N et al. 2015. Myofascial trigger points as a cause of abnormal cocontraction in Writer's Cramp. Pain Med. 16(10):2041-2045.

Vatthauer KE, Craggs JG, Robinson ME et al. 2015. Sleep is associated with task-negative brain activity in fibromyalgia participants with comorbid chronic insomnia. J Pain Res. 8:819-827. "Patients with chronic pain exhibit altered default mode network (DMN) activity. This preliminary project questioned whether comorbid disease states are associated with further brain alterations. Thirteen women with fibromyalgia (FM) only and 26 women with fibromyalgia with comorbid chronic insomnia (FMI) underwent a single night of ambulatory polysomnography and completed a sleep diary each morning for 14 days prior to performing a neuroimaging protocol. Novel imaging analyses were utilized to identify regions associated with significantly disordered sleep that were more active in task-negative periods than task-oriented periods in participants with FMI, when compared to participants with FM. It was hypothesized that core DMN areas (i.e., cingulate cortex, inferior parietal lobule, medial prefrontal cortex, medial temporal cortex, precuneus) would exhibit increased activity during task-negative periods. Analyses revealed that significantly disordered sleep significantly contributed to group differences in the right cingulate gyrus, left lentiform nucleus, left anterior cingulate, left superior gyrus, medial frontal gyrus, right caudate, and the left inferior parietal lobules. Results suggest that FMI may alter some brain areas of the DMN, above and beyond FM. However, future work will need to investigate these results further by controlling for chronic insomnia only before conclusions can be made regarding the effect of FMI comorbidity on the DMN."

Vaz C, Couto M, Duarte C et al. 2009.  [An unusual case of generalized pain: paramyloidosis simulating fibromyalgia]  Acta Reumatol Port. 34(2B):431-435.  [Portuguese] [Fibromyalgia central sensitization is maintained by something, whether it be myofascial TrP pain or another underlying co-existing condition.   Diagnosis does not stop with a FM label but must include searching for the cause of the central sensitization.  DJS]

Vecchiet L, Vecchiet J, Giamberardino MA. 1999.  Referred muscle pain: clinical and pathophysiologic aspects.  Curr Rev Pain 3(6):489-498.  Referred pain is common in medicine, and the average practitioner in general practice encounters it frequently.  [One wonders why the concept of referred pain from myofascial TrPs is met with such resistance. DJS]

Vega-Ramírez MT, Becerril-Villanueva E, Maldonado-García JL, et al. 2024. S100 proteins: a new frontier in fibromyalgia research. Mol Brain. 2024 May 26;17(1):29. "Recent research has identified S100 proteins as a new area of interest in fibromyalgia studies. These proteins are a group of small molecular weight proteins involved in inflammation and various functions inside and outside of cells, and they may play a critical role in the development and progression of FM."

Velazquez-Saornil J, Ruíz-Ruíz B, Rodríguez-Sanz D et al. 2017. Efficacy of quadriceps vastus medialis dry needling in a rehabilitation protocol after surgical reconstruction of complete anterior cruciate ligament rupture. Medicine (Baltimore). 96(17):e6726. "Quadriceps vastus medialis TrP-DN in conjunction with a rehabilitation protocol in subacute patients with surgical reconstruction of complete ACL rupture increases ROM (short-term) and functionality (short- to mid-term). Although there was an increase in pain intensity with the addition of TrP-DN, this was not detected beyond immediately after the first treatment. Furthermore, stability does not seem to be modified after TrP-DN." Free Article

Veldhuijzen DS, Sondaal SF, Oosterman JM. 2012. Intact cognitive inhibition in patients with fibromyalgia but evidence of declined processing speed. J Pain. 13(5):507-515. "Patients with fibromyalgia frequently report cognitive complaints. In this study we examined performance on 2 cognitive inhibition tests, the Stroop Color-Word Test (SCWT) and the Multi-Source Interference Test (MSIT), in 35 female patients with fibromyalgia and 35 age-matched healthy female controls....For patients, pain ...correlated significantly to several indices of cognition. Psychosocial variables were not related to cognitive test performance. Fibromyalgia patients performed worse on both tests but to a similar extent for the neutral condition and the interference condition, indicating that there is no specific problem in cognitive inhibition. Evidence of decreased mental processing and/or psychomotor speed was found in patients with fibromyalgia. PERSPECTIVE: Fibromyalgia patients performed worse on interference tests, but no specific problem in cognitive inhibition was found. Decreased reaction time performance may instead point to an underlying problem of psychomotor or mental processing speed in fibromyalgia. Future studies should examine potential deficits in psychomotor function in fibromyalgia patients in more detail."

Venancio Rde A, Alencar FG Jr, Zamperini C. 2009.  Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches.  Cranio. 27(1):46-53.  “Statistically, all the groups showed favorable results for the evaluated requisites…, except for the use of rescue medication and local post injection sensitivity….”  “Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory.”

Verne GN, Robinson ME, Vase L et al. 2003.  Reversal of visceral and cutaneous hyperalgesia by local rectal anesthesia in irritable bowel syndrome (IBS) patients.  Pain 105(1-2):223-30. This article deals with altered visceral perception in IBS.  The researchers found that using topical anesthetic (lidocaine) rectally effectively decreased visceral and cutaneous hyperalgesia in these patients.  They concluded that this was a central blockade, but perhaps topical application of lidocaine on area myofascial trigger points could have been involved.  More medical researchers need to become aware of the reality and scope of myofascial trigger points.

Vervoort VM, Vriezekolk JE, Olde Hartman TC et al. 2018. Cognitive-behavioural and social factors do not predict recurrent secondary healthcare use in patients with fibromyalgia: a longitudinal study. Clin Exp Rheumatol. [Nov 29 Epub ahead of print] "Healthcare use in fibromyalgia (FM) is relatively high. Besides disease-related variables, cognitive-behavioural factors have been concurrently associated with healthcare use…. Our results suggest that the existence of comorbidities as communicated by the patient is the strongest warning signal for recurrent secondary healthcare use in FM. There seems no value in using cognitive-behavioural and social factors for early identification of patients with FM at risk for recurrent secondary healthcare use."

Vgontzas A.N., Papanicolaou D.A., Bixler, E.O., Hopper K., Lotsikas A., Lin H.M., Kales A., Chrousos G.P. 2000. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J. Clin Endocrinol Metab. 85(3):1151-8. Sleep apnea is associated with daytime sleepiness and fatigue, abdominal obesity, and insulin resistance.

Vgontzas, A. N. , G. Mastorakos, E. O. Bixter, A. Kales, P. W. Gold and G. P. Chrousos. 1999. Sleep deprivation effects on the activity of the hypothalamus-pituitary-adrenal and growth axes: potential clinical implications. Clin Endocrinol (Oxf) 51(2):205-215.

Vicente Palacio E, Franco de Castro A, Adot Zurbano JM, Medina et al. 2020. Physical exam in the evaluation of bladder pain syndrome (BPS): A key component for differential diagnosis. Arch Esp Urol. 73(4):281-292. "Myofascial involvement was observed in 28.4% of the 296 cases of BPS who received a PE (physical exam)."

Vignaux G, Besnard S, Denise P et al. 2015. The vestibular system: A newly identified regulator of bone homeostasis acting through the sympathetic nervous system. Curr Osteoporos Rep. [May 28 Epub ahead of print.] "The vestibular system is a small bilateral structure located in the inner ear, known as the organ of balance and spatial orientation. It senses head orientation and motion, as well as body motion in the three dimensions of our environment. It is also involved in non-motor functions such as postural control of blood pressure. These regulations are mediated via anatomical projections from vestibular nuclei to brainstem autonomic centers and are involved in the maintenance of cardiovascular function via sympathetic nerves. Age-associated dysfunction of the vestibular organ contributes to an increased incidence of falls, whereas muscle atrophy, reduced physical activity, cellular aging, and gonadal deficiency contribute to bone loss. Recent studies in rodents suggest that vestibular dysfunction might also alter bone remodeling and mass more directly, by affecting the outflow of sympathetic nervous signals to the skeleton and other tissues. This review will summarize the findings supporting the influence of vestibular signals on bone homeostasis, and the potential clinical relevance of these findings."

Vij B, Whipple MO, Tepper SJ et al. 2015. Frequency of migraine headaches in patients with fibromyalgia. Pain Physician. 18(3):E389-401. "The results of this study suggest that migraine headaches are common in patients with fibromyalgia. Clinicians who care for either population must be aware that these conditions commonly overlap and can significantly increase a patient's cumulative disease burden."

Villafaina S, Collado-Mateo D, Fuentes-Garcia JP et al. 2019. Impact of fibromyalgia on Alpha-2 EEG power spectrum in the resting condition: A descriptive correlational study. Biomed Res Int. Apr 1;2019:7851047. "The fibromyalgia group exhibited decreased alpha-2 power in central, temporoparietal, and occipital brain areas… Interestingly, pain correlated negatively with alpha-2 in Cz, P4, and Pz only in the fibromyalgia group.

Villafaina S, Tomas-Carus P, Silva V, et al. The behavior of muscle oxygen saturation, oxy and deoxy hemoglobin during a fatigue test in fibromyalgia. Biomedicines. 2023 Jan 4;11(1):132. This study explored changes in oxygen saturation, oxy and deoxy hemoglobin in FM patients and healthy controls (HC) during a fatigue producing repetitive exercise protocol. There were significant differences. The patients were not assessed for co-existing myofascial trigger points, which are known to produce rapid fatiguability and slow recovery. It would certainly be of interest to know if the changes were due to something else, such as FM, co-existing TrPs, or both. DJS]

Villafane JH, Lopez-Royo MP, Herrero P et al. 2019. Prevalence of myofascial trigger points in post-stroke patients with painful shoulders: a cross sectional study. PM R. [Feb 7 Epub ahead of print] "In patients with stroke, hemiplegic shoulder pain can be a major problem." A total of 50 stroke patients with shoulder pain were evaluated for MTrPs located in infraspinatus, supraspinatus, teres minor, and upper trapezius was studied, using the diagnosis criteria recommended by Simons, Travell, and Simons."The prevalence of latent MTrPs was estimated to have a rate of 68%, 92%, 40% and 62% for supraspinatus, infraspinatus, teres minor, and upper trapezius muscle, respectively. The prevalence of active MTrPs was estimated to have a rate of 34%, 50%, 12% and 20% for supraspinatus, infraspinatus, teres minor, and upper trapezius muscle respectively."

Vincent A, Whipple MO, Low PA et al. 2015. Patients with fibromyalgia have significant autonomic symptoms but modest autonomic dysfunction. PM R. Aug 24. [Epub ahead of print] This research from the Mayo Clinic looks at variables that might be impacting the autonomic involvement in FM patients. They use a 6 Minute Walk Test coupled with oxygen volume. They found: "Patients with fibromyalgia report more severe symptoms across all domains including physical activity and autonomic symptoms when compared to controls, but the objective assessments only showed modest differences. Our results suggest that patients with widespread subjective impairment of function have only modest objective measures of autonomic dysfunction. We recommend that the primary treatment goal should be focused on restoration of function which may also ameliorate symptoms."

Vincent A, Whipple MO, McAllister SJ et al. 2015. A cross-sectional assessment of the prevalence of multiple chronic conditions and medication use in a sample of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota. BMJ Open. 5(3):e006681. "The objective of this study was to evaluate the problem of multiple chronic conditions and polypharmacy in patients with fibromyalgia….Medical record review demonstrated that greater than 50% of the sample had seven or more chronic conditions. Chronic joint pain/degenerative arthritis was the most frequent comorbidity (88.7%), followed by depression (75.1%), migraines/chronic headaches (62.4%) and anxiety (56.5%). Approximately, 40% of patients were taking three or more medications for symptoms of fibromyalgia. Sleep aids were the most commonly prescribed medications in our sample (33.3%) followed by selective serotonin reuptake inhibitors (28.7%), opioids (22.4%) and serotonin norepinephrine reuptake inhibitors (21.0%)….The results of our study highlight the problem of multiple chronic conditions and high prevalence of polypharmacy in fibromyalgia. Clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions when recommending medications." Free Article [This study from the Mayo Clinic did not take into account or note the presence of co-existing myofascial trigger points in these patients, or the results and conclusions might have been different, especially if those TrPs had been treated. Focusing on the psychological problems while ignoring the physiological ones can lead to faulty research. DJS]

Vincent A, Whipple MO, Rhudy LM. 2015. Fibromyalgia Flares: A Qualitative Analysis. Pain Med. [Jan 13 Epub ahead of print.] "Patients with fibromyalgia report periods of symptom exacerbation, colloquially referred to as 'flares' and despite clinical observation of flares, no research has purposefully evaluated the presence and characteristics of flares in fibromyalgia…. A total of 44 participants completed the survey. Responses to the seven open-ended questions revealed three main content areas: causes of flares, flare symptoms, and dealing with a flare. Participants identified stress, overdoing it, poor sleep, and weather changes as primary causes of flares. Symptoms characteristic of flares included flu-like body aches/exhaustion, pain, fatigue, and variety of other symptoms. Participants reported using medical treatments, rest, activity and stress avoidance, and waiting it out to cope with flares….Our results demonstrate that periods of symptom exacerbation (i.e., flares) are commonly experienced by patients with fibromyalgia and symptoms of flares can be differentiated from every day or typical symptoms of fibromyalgia. Our study is the first of its kind to qualitatively explore characteristics, causes, and management strategies of fibromyalgia flares. Future studies are needed to quantitatively characterize fibromyalgia flares and evaluate mechanisms of flares." [The authors from the Mayo Clinic were unaware that the flare initiating events activated trigger points, further provoking central sensitization and the "flare". This may change. DJS]

Viola-Saltzman M, Watson NF, Bogart A et al. 2010. High prevalence of restless legs syndrome among patients with fibromyalgia: a controlled cross-sectional study. J Clin Sleep Med. 6(5):423-427. "There is a higher prevalence and odds of RLS in those with FM compared to controls. Clinicians should routinely query FM patients regarding RLS symptoms because treatment of RLS can potentially improve sleep and quality of life in these patients." [One must wonder how many of these patients also have TrPs, as TrPs have been shown to be a factor in RLS, and these patients were not checked for co-existing TrPs. DJS]

Violet TK. 2019. Constructing the gendered risk of illness in Lyrica ads for fibromyalgia: Fear of isolation as a motivating narrative for consumer demand. J Med Humanit. [Sep 2 Epub ahead of print] "Direct-to-consumer television advertisements for Lyrica in the United States create narratives of gendered domestic normalcy to which women with fibromyalgia are encouraged to aspire through pharmaceutical intervention. This paper unpacks images and narratives within these advertisements to demonstrate that they rely on metaphors that represent gendered expectations in order to evoke guilt and provoke a desire for what Joseph Dumit calls "health as risk reduction," and what I argue is an attempt to show disability being erased. Following Stuart Hall's Encoding/Decoding model of communication, viewers play a role in constructing societal expectations for women with chronic pain and for themselves."

Visser EJ, Ramachenderan J, Davies SJ et al. 2014. Chronic Widespread Pain Drawn on a Body Diagram is a Screening Tool for Increased Pain Sensitization, Psycho-Social Load, and Utilization of Pain Management Strategies. Pain Pract. [Dec 3 Epub ahead of print.] "This study demonstrates that calculating PPSA (percentage pain surface area) on a body diagram [using the RON (rule of nines) method] is a valid and convenient 'snapshot' screening tool to identify patients with an increased likelihood of pain sensitization, psycho-social load, and utilizing pain management resources."

Vitali C, Del Papa N. 2015. Pain in primary Sjogren's syndrome. Best Pract Res Clin Rheumatol. 29(1):63-70. Joint and muscle pain are commonly observed in patients with primary Sjogren's syndrome (pSS). Different types of pain can be distinguished, that is, articular pain, neuropathic pain and widespread pain. Articular pain is due to more or less evident synovitis, usually involving peripheral joints such as hand joints, wrists, knees and ankles. Drugs used to treat rheumatoid arthritis, or lupus synovitis, are also employed for articular involvement in pSS. Pure sensory neuropathies and, more often, small fibre neuropathies are responsible for neuropathic pain in pSS. This is usually localized in the legs and arms with a characteristic glove or sock distribution. Widespread pain, often assuming the features of fibromyalgia, has also been reported in patients with pSS. The pathological mechanisms underlying both neuropathic pain and widespread (fibromyalgia) pain in pSS have not been so far completely clarified."

Vij M, Dua A, Davies A et al. 2021. Do patients with central sensitivity syndromes have poor subjective outcomes despite anatomical cure from pelvic organ prolapse surgery? Int Urogynecol J. Jan 18. Online ahead of print. "There is a less favourable outcome of POP surgery in women with CSS compared to those without in terms of persistence of symptoms, pain and overall satisfaction." [It would be interesting to discover how many of these dissatisfied patients has co-existing and untreated MTrPs. DJS]

Voepel-Lewis T, Caird MS, Tait AR et al. 2017. A high preoperative pain and symptom profile predicts worse pain outcomes for children after spine fusion surgery. Anesth Analg. [Mar 17 Epub ahead of print.] "Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes…. A behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain."

Volkers L, Mechioukhi Y, Coste B. 2014. Piezo channels: from structure to function. Pflugers Arch. [Jul 20 Epub ahead of print.] "Mechanotransduction is the conversion of mechanical stimuli into biological signals. It is involved in the modulation of diverse cellular functions such as migration, proliferation, differentiation, and apoptosis as well as in the detection of sensory stimuli such as air vibration and mechanical contact. Therefore, mechanotransduction is crucial for organ development and homeostasis and plays a direct role in hearing, touch, proprioception, and pain. Multiple molecular players involved in mechanotransduction have been identified in the past, among them ion channels directly activated by cell membrane deformation. Most of these channels have well-established roles in lower organisms but are not conserved in mammals or fail to encode mechanically activated channels in mammals due to non-conservation of mechanotransduction property. A family of mechanically activated channels that counts only two members in human, piezo1 and 2, has emerged recently. Given the lack of valid mechanically activated channel candidates in mammals in the past decades, particular attention is given to piezo channels and their potential roles in various biological functions. This review summarizes our current knowledge on these ion channels."

von Deneen KM, Alemayehu DG, Khosla A. 2024. Acute compartment syndrome and rhabdomyolysis caused by a single electrical muscle stimulation in a 46-year-old female professional athlete with fibromyalgia, chronic fatigue syndrome, and myofascial disorder: A case report. Clin J Sport Med. 2024 Sep 1;34(5):506-508. "Electrical muscle stimulation training poses an increased risk of severe complications in individuals with chronic diseases and myopathy. Therefore, careful subject selection is required for EMS training in individuals with chronic diseases and myopathy to prevent common side effects. For individuals trying EMS training for the first time, it is recommended to avoid high-frequency EMS exercises." [There can be dangers in repetitious exercise. DJS]

von Kanel R, Muller-Hartmannsgruber V, Kokinogenis G et al. 2014. Vitamin D and Central Hypersensitivity in Patients with Chronic Pain. Pain Med. [Apr 14 Epub ahead of print.] "The findings suggest a role of low vitamin D levels for heightened central sensitivity, particularly augmented pain processing upon mechanical stimulation in chronic pain patients. Vitamin D seems comparably less important for self-reports of spontaneous chronic pain."

Von Stulpnagel C, Reilich P, Straube A et al. 2009.  Myofascial trigger points in children with tension-type headache: a new diagnostic and therapeutic option.  J Child Neurol. 24(4):406-409.  “These preliminary findings suggest a role for active trigger points in children with tension-type headache.  Trigger point-specific physiotherapy seems to be an effective therapy in these children.”

Von Stulpnagel C, Blaschek A, Lee SH et al. 2006.  [Primary headache in children]  MMW Fortschr Med. 148(46):39-41. [German]  “...treatment of headaches is integrative and multimodal, and includes pharmacotherapy, psychological interventional measures, modification of the daily routine (e.g., drinking, sleeping) and trigger point-based physiotherapy.”

Vriezekolk JE, Peters AJF, van den Ende CHM et al. 2019. Solicitous and invalidating responses are associated with health-care visits in fibromyalgia. Rheumatol Adv Pract. 3(1):rkz008. "Health-care use in FM is substantial. Besides the severity of the disease and psychological factors, previous research suggests that the social environment can influence patients' health-care use … Being female, paid employment, having a comorbid condition, a higher severity of FM, more partner's solicitous responses and more invalidating responses by family were univariately associated with visits to a physician. Having a comorbid condition, severity of FM and invalidation by family were uniquely associated with visits to a physician.

Vulfsons S, Minerbi A. 2020. The case for comorbid myofascial pain-A qualitative review. Int J Environ Res Public Health. Jul 17;17(14):E5188. "Myofascial pain syndrome is widely considered to be among the most prevalent pain conditions, both in the community and in specialized pain clinics. While myofascial pain often arises in otherwise healthy individuals, evidence is mounting that its prevalence may be even higher in individuals with various comorbidities. Comorbid myofascial pain has been observed in a wide variety of medical conditions, including malignant tumors, osteoarthritis, neurological conditions, and mental health conditions. Here, we review the evidence of comorbid myofascial pain and discuss the diagnostic and therapeutic implications of its recognition." [Chronic pain patients may have multiple and sometimes interacting diagnoses, and MTrPs are ubiquitous. DJS]

Vulfsons S, Ratmansky M, Kalichman L. 2012. Trigger point needling: techniques and outcome. Curr Pain Headache Rep. 16(5):407-412. "In this review we provide the updates on last years' advancements in basic science, imaging methods, efficacy, and safety of dry needling of myofascial trigger points (MTrPs). The latest studies confirmed that dry needling is an effective and safe method for the treatment of MTrPs when provided by adequately trained physicians or physical therapists. Recent basic studies have confirmed that at the site of an active MTrP there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response. Two new modalities, sonoelastography and magnetic resonance elastography, were recently introduced allowing noninvasive imaging of MTrPs. MTrP dry needling, at least partially, involves supraspinal pain control via midbrain periaqueductal gray matter activation. A recent study demonstrated that distal muscle needling reduces proximal pain by means of the diffuse noxious inhibitory control. Therefore, in a patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling."

Vuong C, Van Uum SHM, O'Dell LE et al. 2010. The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev. 31(1): 98-132. This review is primarily concerned with opioid abuse, yet contains much information relevant to legitimate opioid use and its effect on the endocrine systems. Most studies concerned acute use, although chronic use caused more significant endocrine changes. "In humans and laboratory animals, opioids generally increase GH and prolactin and decrease LH, testosterone, estradiol, and oxytocin. In humans, opioids increase TSH, whereas in rodents, TSH is decreased. In both rodents and humans, the reports of effects of opioids on arginine vasopressin and ACTH are conflicting. Opioids act preferentially at different receptor sites leading to stimulatory or inhibitory effects on hormone release. Increasing opioid abuse primarily leads to hypogonadism but may also affect the secretion of other pituitary hormones. The potential consequences of hypogonadism include decreased libido and erectile dysfunction in men, oligomenorrhea or amenorrhea in women, and bone loss or infertility in both sexes. Opioids may increase or decrease food intake, depending on the type of opioid and the duration of action. Additionally, opioids may act through the sympathetic nervous system to cause hyperglycemia and impaired insulin secretion."

Wach J, Letroublon MC, Coury F et al. 2016. Fibromyalgia in spondyloarthritis: Effect on disease activity assessment in clinical practice. J Rheumatol. [Sep 15 Epub ahead of print.] Spondyloarthritis (SpA) is the second most frequent inflammatory rheumatic disease, characterized by spinal involvement, peripheral arthritis, or enthesitis with marked pain, stiffness, and fatigue. Fibromyalgia (FM) may be associated with SpA, and shares some common symptoms. FM is a frequent comorbidity in patients with SpA, especially in peripheral forms. In patients with SpA-FM, disease activity may be overestimated when measured by some tests [BASDAI Bath Ankylosing Spondylitis Disease Activity Index and to a lesser extent by ASDAS-CRP Ankylosing Spondylitis Disease Activity Score], and this could lead to inappropriate treatment escalation.

Wada JT, Akamatsu F, Hojaij F et al. 2020. An anatomical basis for the myofascial trigger points of the abductor hallucis muscle. Biomed Res Int. Jan 22;2020:9240581. "Myofascial pain syndrome is characterized by pain and a limited range of joint motion caused by muscle contracture related to motor-end-plate dysfunction and the presence of myofascial trigger points (MTrPs). It is the most frequent cause of musculoskeletal pain, with a worldwide prevalence varying between 13.7% and 47%. Of the patients with myofascial pain syndrome, approximately 17% have pain in the medial hindfoot area. The abductor hallucis muscle is located in the medial, posterior region of the foot and is related to painful plantar syndromes. … A high concentration of nerve branches was observed in the first quadrant (Q1) of the abductor hallucis muscle, which is the same area in which the MTrPs are described. The topography of the entry points of the branches of the medial plantar nerve to the abductor hallucis muscle correlates with the topography of the muscular trigger points."

Wagner B, Kagan-HAllet KS, Russell IJ. 2003.  Concomitant presentation of adermatopathic dermatomyositis, statin myopathy, fibromyalgia syndrome, piriformis muscle myofascial pain syndrome, and diabetic neuropathy.  J Muscoloskel Pain 11(2):25-30.  This interesting case study details how complex chronic pain diagnosis and treatment can be and teaches a good lesson why it is very important not to ascribe all chronic pain symptoms to one syndrome.  It takes knowledge, care and time to optimize the quality of life of a patient with multiple conditions.

Wagner JS, Chandran A, DiBonaventura M et al. 2013. The costs associated with sleep symptoms among patients with fibromyalgia. Expert Rev Pharmacoecon Outcomes Res. 13(1):131-139. "Among the FM population, sleep symptoms were prevalent and associated with higher direct and indirect costs, suggesting improved management may have long-term cost savings." [This leads one to wonder why Xyrem is not approved for deep-sleep-deprived patients with FM. DJS]

Wagner JS, Dibonaventura MD, Chandran AB et al. 2012. The association of sleep difficulties with health-related quality of life among patients with fibromyalgia. BMC Musculoskel Disord. 13(1):199. "Among the FM population, sleep difficulty symptoms were independently associated with clinically-meaningful decrements in mental and physical HRQoL (health-related quality of life). These results suggest that greater emphasis in the treatment of sleep difficulty symptoms among the FM population may be warranted."

Walitt B, Ceko M, Gracely J et al. 2015. Neuroimaging of Central Sensitivity Syndromes: Key insights from the scientific literature. Curr Rheumatol Rev. [Dec 30 Epub ahead of print.] "Central sensitivity syndromes are characterized by distressing symptoms, such as pain and fatigue, in the absence of clinically obvious pathology. The scientific underpinnings of these disorders are not currently known. Modern neuroimaging techniques promise new insights into mechanisms mediating these postulated syndromes. We review the results of neuroimaging applied to five central sensitivity syndromes: fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, temporomandibular joint disorder, and vulvodynia syndrome. Neuroimaging studies of basal metabolism, anatomic constitution, molecular constituents, evoked neural activity, and treatment effect are compared across all of these syndromes. Evoked sensory paradigms reveal sensory augmentation to both painful and non-painful stimulation. This is a transformative observation for these syndromes, which were historically considered to be completely of hysterical or feigned in origin. However, whether sensory augmentation represents the cause of these syndromes, a predisposing factor, an endophenotype, or an epiphenomenon cannot be discerned from the current literature. Further, the result from cross-sectional neuroimaging studies of basal activity, anatomy, and molecular constituency are extremely heterogeneous within and between the syndromes. A defining neuroimaging "signature" cannot be discerned for any of the particular syndromes or for an over-arching central sensitization mechanism common to all of the syndromes. Several issues confound initial attempts to meaningfully measure treatment effects in these syndromes. At this time, the existence of 'central sensitivity syndromes' is based more soundly on clinical and epidemiological evidence. A coherent picture of a 'central sensitization' mechanism that bridges across all of these syndromes does not emerge from the existing scientific evidence."

Walitt B, Nahin RL, Katz RS et al. 2015. The prevalence and characteristics of fibromyalgia in the 2012 National Health Interview Survey. PLoS One. 10(9):e0138024. "Examination of the surrogate polysymptomatic distress scale (PSD) of the 2010 ACR criteria found fibromyalgia symptoms extending through the full length of the scale….Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. The association of fibromyalgia-like symptoms over the full length of the PSD scale with physiological as well as mental stressors suggests PSD may be a universal response variable rather than one restricted to fibromyalgia." Free PMC Article

Walker, E. A., D. Keegan, G. Gardner, M. Sullivan, D. Bernstein and W. J. Katon. 1997.Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosom Med 59(6):572-577.

Walker, E. A., J. Unutzer and W. J. Katon. 1998. Understanding and caring for the distressed patient with multiple medically unexplained symptoms. J Am Board Fam Pract 11(5):347-56.

Wall R. 2014. Introduction to myofascial trigger points in dogs. Top Companion Anim Med. 29(2):43-48. "In dogs, muscles make up 44%-57% of total body weight and can serve as source of both pain and dysfunction when myofascial trigger points are present. However, rarely is muscle mentioned as a generator of pain in dogs, and even less mentioned is muscle dysfunction. The veterinary practitioner with interest in pain management, rehabilitation, orthopedics, and sports medicine must be familiar with the characteristics, etiology, and precipitating factors of myofascial trigger points. Additionally, the development of examination and treatment skill is needed to effectively manage myofascial trigger points in dogs." [Dogs, horses, and other animals have been found to have myofascial trigger points too. They have myofascia, so they can get trigger points. DJS]

Wallace M, Moulin DE, Rauck RL et al. 2009.  Long-term safety, tolerability, and efficacy of OROS hydromorphone in patients with chronic pain.  J Opioid Manag. 5(2):97-105.  “Once-daily OROS hydromorphone is an osmotically driven, controlled-release preparation that may be particularly well suited to long-term use, because it provides consistent plasma concentrations and sustained around-the-clock analgesia.  In this study, the benefits of OROS hydromorphone attained in short-term studies were maintained in the long-term when daily administration was continued.”

Wallace SL, Miller LD, Mishra K. 2019. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. [Oct 11 Epub ahead of print] "Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT (pelvic floor physical therapy) is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. ….PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness."

Wallden M. 2013. The primal nature of core function: In rehabilitation & performance conditioning. J Bodyw Mov Ther. 17(2):239-248. "In this editorial, what is understood of the definition and function of the human core is discussed; presented in the context of evolution and holistic human modeling. It appears likely from this understanding of neural phenomena such as central sensitization, neural facilitation/inhibition, tonic and phasic motoneuron excitatory thresholds and viscerosomatic convergence that, very simply, for effective core function, optimal visceral function is a pre-requisite and may be a commonly overlooked aspect of patient rehabilitation. Furthermore, not only is core function key for optimal expression of forces through the appendicular skeleton, but since it is the tonic motoneurons most readily inhibited by nociceptive (including viscerosomatic) phenomena, this will likely affect the tonic components of peripheral musculature directly; impairing both local motor control and performance at peripheral joints." [Core muscle dysfunctions are often at the base of peripheral muscle symptoms. The peripheral muscles try to compensate when the core is weakened by trigger points, causing the peripheral muscles to become overloaded and develop their own trigger points (and the pain and dysfunction they cause). Too often this valuable insight is ignored. DJS]

Wallwork SB, Leake HB, Peek AL et al. 2020. Implicit motor imagery performance is impaired in people with chronic, but not acute, neck pain. PeerJ. Feb 14;8:e8553. "People with chronic neck pain have impaired proprioception (i.e., sense of neck position). It is unclear whether this impairment involves disruptions to the proprioceptive representation in the brain, peripheral factors, or both. Implicit motor imagery tasks, namely left/right judgements of body parts, assess the integrity of the proprioceptive representation. Previous studies evaluating left/right neck judgements in people with neck pain are conflicting. We conducted a large online study to comprehensively address whether people with neck pain have altered implicit motor imagery performance….. There is evidence of impaired implicit motor imagery performance in people with chronic neck pain, which may suggest disruptions to proprioceptive representation of the neck. These disruptions seem specific to the neck (performance on hand images intact) but non-specific to the exact location of neck pain."

Walter A, Rigaud J, Labat JJ. 2010. [Irritable bowel syndrome, levator ani syndrome, proctalgia fugax and chronic pelvic and perineal pain.] Prag Urol 20(12):995-1002. [French] These conditions are frequently found together, and may have related initiating and perpetuating factors. [Myofascial trigger points, vertebral disorders, imbalances of neuromodulators, leaky gut, and central sensitization are some of the interactive factors mentioned in this article. DJS]

Walton DM, Elliott JM. 2018. A new clinical model for facilitating the development of pattern recognition skills in clinical pain assessment. Musculoskelet Sci Pract. 36:17-24. "Common, enigmatic musculoskeletal conditions such as whiplash-associated disorder, myofascial pain syndrome, low back pain, headache, fibromyalgia, osteoarthritis, and rotator cuff pathology, account for significant social, economic, and personal burdens on a global scale...Establishing an accurate prognostic or diagnostic profile on a patient-by-patient basis can challenge the insight of both novice and expert clinicians. Questions remain on how and when to choose the right tool(s), at the right time(s), for the right patient(s), for the right problem(s). The aim of this paper is to introduce a new clinical reasoning framework that is simple in presentation but allows interpretation of complex clinical patterns, and is adaptable across patient populations with acute or chronic, traumatic or non-traumatic pain. The concepts of clinical phenotyping (e.g. identifying observable characteristics of an individual resulting from the interaction of his/her genotype and their environment) and triangulation serve as the foundation for this framework. Based on our own clinical and research programs, we present these concepts using two patient cases; a) whiplash-associated disorder (WAD) following a motor vehicle collision and b) mechanical low back pain."

Wan B, Gebauer S, Salas J et al. 2019. Gender-Stratified Prevalence of Psychiatric and Pain Diagnoses in a Primary Care Patient Sample with Fibromyalgia. Pain Med. [Apr 22 Epub ahead of print] "Comorbid psychiatric and pain-related conditions are common in patients with fibromyalgia. Most studies in this area have used data from patients in specialty care and may not represent the characteristics of fibromyalgia in primary care patients. We sought to fill gaps in the literature by determining if the association between psychiatric diagnoses, conditions associated with chronic pain, and fibromyalgia differed by gender in a primary care patient population.... Except for depression and arthritis, the burden of comorbid conditions in patients with fibromyalgia is similar in women and men treated in primary care. Fibromyalgia comorbidities in primary care are similar to those found in specialty care."

Wang C. 2012. Role of tai chi in the treatment of rheumatologic diseases. Curr Rheumatol Rep. 14(6):598-603. "Rheumatologic diseases (e.g., fibromyalgia, osteoarthritis, and rheumatoid arthritis) consist of a complex interplay between biologic and psychological aspects, resulting in therapeutically challenging chronic conditions to control. Encouraging evidence suggests that Tai Chi, a multi-component Chinese mind-body exercise, has multiple benefits for patients with a variety of chronic disorders, particularly those with musculoskeletal conditions. Thus, Tai Chi may modulate complex factors and improve health outcomes in patients with chronic rheumatologic conditions. As a form of physical exercise, Tai Chi enhances cardiovascular fitness, muscular strength, balance, and physical function. It also appears to be associated with reduced stress, anxiety, and depression, as well as improved quality of life. Thus, Tai Chi can be safely recommended to patients with fibromyalgia, osteoarthritis, and rheumatoid arthritis as a complementary and alternative medical approach to improve patient well-being."

Wang C, Ge HY, Ibarra JM et al. 2012. Spatial Pain Propagation over Time Following Painful Glutamate Activation of Latent Myofascial Trigger Points in Humans. J Pain. [Apr 25 Epub ahead of print]. "The aim of this present study was to test the hypothesis that tonic nociceptive stimulation of latent myofascial trigger points (MTPs) may induce a spatially enlarged area of pressure pain hyperalgesia….This study shows that MTPs are associated with an early occurrence of a locally enlarged area of pressure hyperalgesia associated with spreading central sensitization. Inactivation of MTPs may prevent spatial pain propagation."

Wang C, Schmid CH, Fielding RA et al. 2018. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. 360:k851. "Tai chi mind-body treatment results in similar or greater improvement in symptoms than aerobic exercise, the current most commonly prescribed non-drug treatment, for a variety of outcomes for patients with fibromyalgia. Longer duration of tai chi showed greater improvement. This mind-body approach may be considered a therapeutic option in the multidisciplinary management of fibromyalgia."

Wang C, Wu Q, Wang Z et al. 2020. Aquaporin 4 knockout increases complete freund's adjuvant-induced spinal central sensitization. Brain Res Bull. Jan 9;156:58-66. This study from China and USA indicates that chronic central pain (central sensitization states such as FM) can be caused or worsened by peripheral pain (such as TrPs, joint pain, other central sensitization states such as migraine or IBS) through the mechanism of the peripheral pain causing activation of glial cells called astrocytes, and suggests a potential target for interrupting this process.

Wang C, Yue H et al. 2020. Microglia mediate forgetting via complement-dependent synaptic elimination. Science. Feb 7;367(6478):688-694. "Synapses between engram cells are believed to be substrates for memory storage, and the weakening or loss of these synapses leads to the forgetting of related memories. We found engulfment of synaptic components by microglia in the hippocampi of healthy adult mice. Depletion of microglia or inhibition of microglial phagocytosis prevented forgetting and the dissociation of engram cells. By introducing CD55 to inhibit complement pathways, specifically in engram cells, we further demonstrated that microglia regulated forgetting in a complement- and activity-dependent manner. Additionally, microglia were involved in both neurogenesis-related and neurogenesis-unrelated memory degradation. Together, our findings revealed complement-dependent synapse elimination by microglia as a mechanism underlying the forgetting of remote memories." [This process may contribute to FM cognitive dysfunction. DJS]

Wang D, Couture R, Hong Y. 2014. Activated microglia in the spinal cord underlies diabetic neuropathic pain. Eur J Pharmacol. [Feb 6 Epub ahead of print.] "Diabetes mellitus is an increasingly common chronic medical condition. Approximately 30% of diabetic patients develop neuropathic pain, manifested as spontaneous pain, hyperalgesia and allodynia. Hyperglycemia induces metabolic changes in peripheral tissues and enhances oxidative stress in nerve fibers. The damages and subsequent reactive inflammation affect structural properties of Schwann cells and axons leading to the release of neuropoietic mediators, such as pro-inflammatory cytokines and pro-nociceptive mediators. Therefore, diabetic neuropathic pain (DNP) shares some histological features and underlying mechanisms with traumatic neuropathy. DNP displays, however, other distinct features; for instance, sensory input to the spinal cord decreases rather than increasing in diabetic patients. Consequently, development of central sensitization in DNP involves mechanisms that are distinct from traumatic neuropathic pain. In DNP, the contribution of spinal cord microglia activation to central sensitization and pain processes is emerging as a new concept. Besides inflammation in the periphery, hyperglycemia and the resulting production of reactive oxygen species affect the local microenvironment in the spinal cord. All these alterations could trigger resting and sessile microglia to the activated phenotype. In turn, microglia synthesize and release pro-inflammatory cytokines and neuroactive molecules capable of inducing hyperactivity of spinal nociceptive neurons. Hence, it is imperative to elucidate glial mechanisms underlying DNP for the development of effective therapeutic agents. The present review highlights the recent developments regarding the contribution of spinal microglia as compelling target for the treatment of DNP."

Wang D, Frey-Law LA. 2022. Multisensory sensitivity differentiates between multiple chronic pain conditions and pain-free individuals. Pain. May 19. Online ahead of print. "Multisensory sensitivity (MSS) to non-painful stimuli has been identified as a risk factor for the presence of coexisting chronic pain conditions (COPCs)…. Our findings support that MSS can differentiate between pain phenotypes with different degrees of expected central mechanism involvement, and also serves as a risk and resilience marker for total COPCs. This supports the use of MSS as a marker of heightened central nervous system processing, and thus may serve as a clinically feasible assessment to better profile pain phenotypes with the goal of improving personalized treatment."

Wang F, Eun-Kyoung Lee O, Feng F et al. 2015. The effect of meditative movement on sleep quality: A systematic review. Sleep Med Rev. 30:43-52. "Findings of the 17 studies showed that MM has beneficial effects for various populations on a range of sleep measures. Improvement in sleep quality was reported in the majority of studies and was often accompanied by improvements in quality of life, physical performance, and depression. However, studies to date generally have significant methodological limitations."

Wang FX, Xu WM, Xu CL, et al. Aquaporins and neuropathic pain. Front Biosci (Landmark Ed). 2023 Feb 24;28(2):35. "Aquaporins (AQPs), mainly responsible for the transport and clearance of water and solute, play important roles in developing CNS diseases, especially neuropathic pain. This review focuses on the interaction of AQPs with neuropathic pain, and the potential of AQPs, especially aquaporins 4, as therapeutic targets."

Wang G, Gao Q, Hou J et al. 2014. Effects of Temperature on Chronic Trapezius Myofascial Pain Syndrome during Dry Needling Therapy. Evid Based Complement Alternat Med. [Oct 14 Epub ahead of print.] "The purpose of this study was to investigate the effects of temperature on chronic trapezius myofascial pain syndrome during dry needling therapy. Sixty patients were randomized into two groups of dry needling (DN) alone (group A) and DN combined with heat therapy group (group B)….Our study suggests that both DN and DN heating therapy were effective in the treatment of trapezius MPS, and that DN heating therapy had better long-term effects than DN therapy."

Wang G, Gao Q, Li J et al. 2016. Impact of needle diameter on long-term dry needling treatment of chronic lumbar myofascial pain syndrome. Am J Phys Med Rehabil. 95(7):483-494. "Forty-eight patients with chronic lumbar myofascial pain syndrome were randomly allocated to 3 groups. They received dry needling with needles of diameter 0.25 (group A), 0.5 (group B), and 0.9 mm (group C). Visual analog scale evaluation and health survey were conducted at baseline and 3 months after the treatment… Visual analog scale score evaluations at 3 months showed efficacy in all groups. Results of 3 months showed that efficacy of treatment with larger needles (0.9-mm diameter) was better than that of smaller ones (0.5-mm diameter). The Short Form (36) Health Survey scores at 3 months indicated that treatments with needles of varying diameters were all effective, and when the results of 3 months were compared, there was no difference between the 3 groups." Free PMC Article

Wang JC, Sung FC, Men M et al. 2017. Bidirectional Association between fibromyalgia and gastroesophageal reflux disease: Two population-based retrospective cohort analysis. Pain. [Jul 3 Epub ahead of print] "Fibromyalgia (FM) tends to co-exist with gastroesophageal reflux disease (GERD)…. The present study suggests a bidirectional relationship between FM and GERD. There is a greater risk of developing GERD for FM patients than developing FM for GERD patients."

Wang KA, Wang JC, Lin CL et al. 2017. Association between fibromyalgia syndrome and peptic ulcer disease development. PLoS One. 12(4):e0175370. "All patients were free of PUD (peptic ulcer disease) at the baseline. Cox proportional hazard regressions were performed to compute the hazard ratio of PUD after adjustment for demographic characteristics and comorbidities. The prevalence of comorbidities was significantly higher in the FMS patients than in the controls." Free Article [I wonder how many of the FM patients had been on meds that irritate the stomach? DJS]

Wang T, Vahdatinia R, Humbert S et al. 2020. Myofascial injection using fascial layer-specific hydromanipulation technique (FLuSH) and the delineation of multifactorial myofascial pain. Medicina (Kaunas). Dec 20;56(12):717. "The data support the hypothesis that multiple fascial layers are responsible for myofascial pain. In particular, for a given patient, pain may develop from discrete combinations of fascial layers unique to each myofascial point. Non-response to treatment of the myofascial unit may represent a centralized pain process. Adequate treatment of myofascial pain may require treatment of each point as a distinct pathologic entity rather than uniformly in a given patient or across patients."

Wang XJ, Ebbert JO, Elizabeth A Gilman EA, et al. Central sensitization symptom severity and patient-provider relationships in a community setting. J Prim Care Community Health. Jan-Dec 2021;12:21501327211031767. "Patients with high CSS symptom severity were more likely to report that doctor(s) had often/always told them that they don't need treatment when they feel like they do...that doctor(s) often/always don't understand them... and that doctor(s) often/always seem annoyed with them when compared with respondents with low-moderate CSS symptom severity.... Patients with high CSS symptom severity were at greater than 5 times odds of reporting being told that their symptoms were "all in their head" when compared to patients with low-moderate symptom severity.... Patients with CSS spectrum disorders experience frequent pain and decreased quality of life. A high degree of CSS symptom severity is associated with negative experiences with healthcare providers, which deters the establishment of a positive provider-patient relationship."

Wang YH, Yin MJ, Fan ZZ et al. 2014. Hyperexcitability to electrical stimulation and accelerated muscle fatiguability of taut bands in rats. Acupunct Med. 32(2):172-177. "Myofascial trigger points contribute significantly to musculoskeletal pain and motor dysfunction and may be associated with accelerated muscle fatiguability. The aim of this study from the Peoples' Republic of China was to investigate the electrically induced force and fatigue characteristics of muscle taut bands in rats. They found that muscles with taut bands (and trigger points) fatigued more easily."

Ware M, Beaulieu P. 2005.  Cannabinoids for the treatment of pain: an update on recent clinical trials.  Pain Res Manag. 10 Suppl A:27A-30A.  “The potential for cannabinoid therapy for chronic pain states is encouraging.  Clinicians working in pain management should be aware of the options becoming available from the cannabinoid class of medications.”

Warren JW, Clauw DJ. 2012. Functional Somatic Syndromes: Sensitivities and Specificities of Self-Reports of Physician Diagnosis. Psychosom Med. [Oct 15 Epub ahead of print]. "Self-report of physician diagnosis did not identify most of the three most venerable functional somatic syndromes, IBS, FM, and, especially, CFS; nor did it identify substantial minorities of individuals with panic disorder and migraine. Self-report of physician diagnosis was particularly poor in recognizing persons with multiple syndromes. The insensitivity of this diagnostic test has effects on not only prevalence and incidence estimates but also correlates, comorbidities, and case recruitment. To reveal individuals with these syndromes, singly or together, queries of symptoms, not diagnoses, are necessary."

Warren JW, Clauw DJ, Wesselmann U et al. 2014. Functional somatic syndromes as risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis. J Psychosom Res. [Sep 16 Epub ahead of print.] "We tested the hypothesis that functional somatic syndromes (FSSs) are risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis (BPS/IC)….In 312 women with incident BPS/IC, we diagnosed seven pre-BPS/IC syndromes: chronic pelvic pain (CPP), fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome (IBS), sicca syndrome, migraine, and panic disorder. Each was defined as present before 12months (existing syndrome) or onset within 12months (new syndrome) prior to BPS/IC onset. Retrospectively, we sought associations between prior hysterectomy and existing FSSs. Prospectively, we studied associations of existing and new syndromes with subsequent hysterectomy.…. Accounting for CPP and IBS, the presence of multiple FSSs (most without pelvic pain) was a separate, independent risk factor for hysterectomy in early BPS/IC. This suggests that patient features in addition to abdominopelvic abnormalities led to this procedure. Until other populations are assessed, a prudent approach to patients who are contemplating hysterectomy (and possibly other surgeries) for pain and who have IBS or numerous FSSs is first to try alternative therapies including treatment of the FSSs."

Wassinger CA, McKinney H, Roane S et al. 2014. The influence of upper body fatigue on dynamic standing balance. Int J Sports Phys Ther. 9(1):40-46. "Physical therapists should be aware of the adverse influence distant fatigue may exhibit on neuromuscular control in muscles not actively involved in the fatiguing exercise. The balance deficits noted may indicate an increased risk of injury with muscle fatigue in muscles not directly contributing to standing balance."