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Fibromyalgia (FM) and
Chronic Myofascial Pain & Dysfunction (CMPD)
For Medical Professionals
annotated by Devin J. Starlanyl

 

 

References for Research Purposes

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NOTE:  New Nomenclature

All material written by me after October 1, 2007, will have the following changes in nomenclature.  I regret any confusion caused by this change, but deem it necessary due to the changes in our current understanding of the conditions involved.

 
The abbreviation for myofascial trigger point, "TrP," is replaced by "MTP." 
 
The term Myofascial Pain Syndrome (MPS) will no longer be used, as current research shows it is not a syndrome but a true myopathy, and thus a true disease.  
 
There are acute MTPs and chronic myofascial pain (CMP) due to MTPs.  Where applicable, CMP will be separated into CMP Stage 1 (without central sensitization) and CMP Stage 2 (with central sensitization).
 
Fibromyalgia (FM) will replace the former term fibromyalgia syndrome (FMS).

 

 

Facco E, Ceccherelli F. 2005.  Myofascial pain mimicking radicular syndromes.  Acta Neurochir 92:147-150.  “Myofascial pain is very often underscored and misunderstood in clinical practice.  In many cases the localization of myofascial pain may resemble other diseases, such as radicular syndromes and even diseases of internal organs.  When vertebral abnormalities are present on CT or MRI, it should be checked whether the cause of pain is radicular, myofascial, or both.  On the other hand, the conventional approach to painful disorders may lead to errors and wrong diagnosis, depending on several factors: a) pain is often considered a symptom of an organic disease; b) the diagnosis is usually directed towards the structural cause of pain only; c) the functional components of the suffering patient are underscored; d) the site of pain may introduce some bias.”

 

Falla D, Bilenkij G, Jull G. 2004.  Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task.  Spine 29(13):1436-1440.  “Patients with neck pain demonstrated greater activation of accessory neck muscles during a repetitive upper limb task compared to asymptomatic controls.”

Falla D, Jull G, Edwards S et al. 2004.  Neuromuscular efficiency of the sternocleidomastoid and anterior scalene muscles in patients with chronic neck pain.  Disabil Rehabil. 26(12):712-717. “Reduced NME in the superficial cervical flexor muscles in patients with neck pain may be a measurable altered muscle strategy for dysfunction in other muscles.  This aberrant pattern of muscle activation appears to be most evident under conditions of low load.  NME, when measured at 25% MVC, may be a useful objective measure for future investigation of muscle dysfunction in patients with neck pain.”

Fallon N, Chiu Y, Nurmikko T et al. 2017. Altered theta oscillations in resting EEG of fibromyalgia syndrome patients. Eur J Pain. [Jul 31 Epub ahead of print] "This study utilized electroencephalographic (EEG) recordings to investigate the relative power of ongoing oscillatory activity in the resting brain…. FM patients exhibited greater pain, tiredness and tension on the day of testing relative to healthy control participants and augmented theta activity in prefrontal and anterior cingulate cortices. No significant differences were seen in other frequency bands. Augmented frontal theta activity in FM patients significantly correlated with measures of tenderness and mean tiredness scores…. The findings indicate that alterations to resting-state oscillatory activity may relate to ongoing tonic pain and fatigue in FM, and manifest in brain regions relevant for cognitive-attentional aspects of pain processing and endogenous pain inhibition. Enhanced low-frequency oscillations were previously seen in FM and other chronic pain syndromes, and may relate to pathophysiological mechanisms for ongoing pain such as thalamocortical dysrhythmia…. Increased prefrontal theta activity may contribute to persistent pain in fibromyalgia or represent the outcome of prolonged symptoms. The findings point to the potential for therapeutic interventions aimed at normalizing neural oscillations, while further research utilizing quantitative analysis of resting EEG could benefit our understanding of fibromyalgia pathophysiology."

Fallon N, Chiu Y, Nurmikko T et al. 2016. Functional connectivity with the default mode network is altered in fibromyalgia patients. PLoS One. 11(7):e0159198. "Our findings demonstrate alterations to functional connectivity between DMN (default mode network) regions and a variety of regions which are important for pain, cognitive and emotional processing in FMS patients, and which may contribute to the development or maintenance of chronic symptoms in FMS." [It may not be the regions themselves that are altered, but the connections between them. DJS] Free Article

Fallon N, Li X, Chiu Y et al. 2015. Altered cortical processing of observed pain in fibromyalgia syndrome patients. J Pain. [May 12 Epub ahead of print.] "FMS patients demonstrate increased activations for pain and non-pain pictures. The findings suggest that even innocuous, everyday visual stimuli with somatic connotations may challenge the emotional state of FMS patients. Our study points towards the importance of cognitive-emotional therapeutic approaches for the treatment of FMS."

Fan A, Pereira B, Tournadre A et al. 2017. Frequency of concomitant fibromyalgia in rheumatic diseases: Monocentric study of 691 patients. Semin Arthritis Rheum. [Jan 18 Epub ahead of print.] "FM-like symptoms are commonly associated with rheumatic diseases. The frequency of FM is particularly high in non-radiographic axial SpA, thus raising questions about the specificity of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria."

Fan A, Tournadre A, Pereira B et al. 2016. Performance of Fibromyalgia Rapid Screening Tool (FiRST) to detect fibromyalgia syndrome in rheumatic diseases. Rheumatology (Oxford). [Jun 15 Epub ahead of print.] The Fibromyalgia Rapid Screening Tool (FiRST) self-questionnaire for the detection of FM associated with inflammatory rheumatic diseases is about as accurate as a rheumatologist, although if an inflammatory rheumatic illness is co-existent, it is not as efficient. This study did not take into consideration confusion with possible trigger points, but it lets us know that there is such a tool. DJS]

Fan YH, Lin AT, Lu SH et al. 2014. Non-bladder conditions in female Taiwanese patients with interstitial cystitis/hypersensitive bladder syndrome. Int J Urol. [Apr 13 Epub ahead of print.] "Interstitial cystitis/hypersensitive bladder syndrome patients are more likely to have multiple non-bladder conditions. These conditions correlate with the severity of interstitial cystitis/hypersensitive bladder syndrome symptoms."

Farella M., Michelotti A., Gargano A et al. 2002. Myofascial pain syndrome misdiagnosed as odontogenic pain: a case report.  Cranio 20(4):307-11.  When the cause of dental pain cannot be clearly identified, consider all possible causes of dental pain, including the nonodontogenic ones such as myofascial pain, before any irreversible dental procedures are considered.

Farajidavar A, Gharibzadeh S, Towhidkhah F et al. 2006.  A cybernetic view on wind-up.  Med Hypotheses [Mar 21 Epub ahead of print]  “Wind-up may aggravate the pain in clinical hyperalgesic situations such as post-surgical states, some neuropathic pains, fibromyalgia syndrome, and post-herpetic neuralgia.  [This work was based on wind-up in Abeta fibers, and other wind-up studies have been based on afferent C-fibers. DJS]

Farina S, Casarotto M, Benelle M et al. 2004.  A randomized controlled study on the effect of two different treatments (FREMS AND TENS) in myofascial pain syndrome.  N Eura Medicophys. 40(4):293-301.  Both methods appeared effective for myofascial pain, although FREMS seemed better.

Faro M, Saez-Francas N, Castro-Marrero J et al. 2014. [Impact of fibromyalgia in the chronic fatigue syndrome.] Med Clin (Barc). [Jan 2 Epub ahead of print.] [Article in Spanish] "Different studies have showed association of the chronic fatigue syndrome (CFS) with other pathologies, including fibromyalgia (FM)….We included 980 CFS patients (mean age: 48±9 years; 91% women). Fibromyalgia was present in 528 patients (54%). The level of fatigue… and pain … was higher in FM patients. Patients with CFS and FM had more prevalence of sleep-related phenomena. The percentage of patients and the degree of severity of cognitive symptoms, neurological and autonomic dysfunction was higher in FM patients…. FM patients scored higher on the fatigue impact scale … and showed worse results in the quality of life questionnaire….FM (patients have) co-morbidity (with) worse clinical parameters, fatigue and the perception of quality of life (than) in CFS patients."

Farrar JT, Messina J, Xie F et al. 2010. A novel 12-week study, with three randomized, double-blind placebo-controlled periods to evaluate fentanyl buccal tablets for the relief of breakthrough pain in opioid-tolerant patients with noncancer-related chronic pain. Pain Med. 11(9):1313-1327. "FBT (fentanyl buccal tablet) showed continued clinically important analgesic effects and was generally well tolerated over 12 weeks of treatment." Free Article

Fass R, Naliboff BD, Fass SS et al. 2007.  The effect of auditory stress on perception of intraesophageal acid in patients with gastroesophageal reflux disease.  Gastroenterology [Dec 7 Epub ahead of print].  “Acute auditory stress can exacerbate heartburn symptoms in GERD patients by enhancing perceptual response to intraesophageal acid exposure.  This greater perceptual response is associated with greater emotional responses to the stressor.”  [For those of us with FM amplification and GERD, auditory stress may be an even greater peril. DJS]

Fass, R, Quan SF, O’Connor GT et al. 2005.  Predictors of heartburn during sleep in a large prospective cohort study.  Chest 127:1658-1666.  “Heartburn during sleep is very common in the general population.  Reports of this type of symptom of GERD are strongly associated with increased BMI, carbonated soft drink consumption, snoring and daytime sleepiness, insomnia, hypertension, asthma, and usage of benzodiazepines.  Overall, heartburn during sleep may be associated with sleep complaints and excessive daytime sleepiness.”

Fava A, Plastino M, Cristiano D et al. 2013. Insulin resistance possible risk factor for cognitive impairment in fibromyalgic patients. Metab Brain Dis. [Jul 28 Epub ahead of print]. "The results of this study suggest that IR (insulin resistance) may represent a risk factor for memory impairment in fibromyalgic patients." [We have found IR to be a common interactive co-existing condition with both FM and CMP, and mentioned it as a cause of cognitive deficits in "Fibromyalgia and Chronic Myofascial Pain: A Survival Guide". DJS]

Fayaz A, Ayis S, Panesar SS et al. 2016. Assessing the relationship between chronic pain and cardiovascular disease: A systematic review and meta-analysis. Scand J Pain. 13:76-90. "While the psychosocial impact of chronic pain is already well established, little is known about the potential biological consequences. Chronic pain may be associated with an increased prevalence of cardiovascular disease, an effect that has been demonstrated across a spectrum of chronic pain conditions including low back pain, pelvic pain, neuropathic pain and fibromyalgia….Our review supports a possible dose-response type of association between chronic pain and cardiovascular disease, supported by a range of observational studies originating from different countries. Such research has so far failed to satisfactorily rule out that the association is due to confounding variables. What is now needed are further population based longitudinal studies that are designed to allow more robust exploration of a cause and effect relationship….Given the high prevalence of chronic pain in developed and developing countries our results highlight a significant, but underpublicized, public health concern. Greater acknowledgement of the potentially harmful biological consequences of chronic pain may help to support regional, national and global initiatives aimed at reducing the burden of chronic pain."

Fede C, Albertin G, Petrelli L. 2016. Expression of the endocannabinoid receptors in human fascial tissue. Eur J Histochem. 60(2):2643. Cannabinoid receptors have been identified in both the central and peripheral nervous systems. This study found them in the fascia, "suggesting that the endocannabinoid system may help resolve myofascial trigger points and relieve symptoms of fibromyalgia." The cannabinoid receptors 1 and 2 were found in samples volunteered by orthopedic surgery patients. "Both cannabinoid receptors are expressed in human fascia and in human fascial fibroblasts culture cells, although to a lesser extent than the control gene. We can assume that the expression of mRNA and protein of CB1 and CB2 receptors in fascial tissue are concentrated into the fibroblasts. This is the first demonstration that the fibroblasts of the muscular fasciae express CB1 and CB2. The presence of these receptors could help to provide a description of cannabinoid receptors distribution and to better explain the role of fasciae as pain generator and the efficacy of some fascial treatments. Indeed the endocannabinoid receptors of fascial fibroblasts can contribute to modulate the fascial fibrosis and inflammation." Free Article

Fede C, Albertin G, Petrelli L et al. 2016. Hormone receptor expression in human fascial tissue. Eur J Histochem. 60(4):2710. "Many epidemiologic, clinical, and experimental findings point to sex differences in myofascial pain in view of the fact that adult women tend to have more myofascial problems with respect to men. It is possible that one of the stimuli to sensitization of fascial nociceptors could come from hormonal factors such as estrogen and relaxin, that are involved in extracellular matrix and collagen remodeling and thus contribute to functions of myofascial tissue….. Our results are the first demonstrating that the fibroblasts located within different districts of the muscular fasciae express sex hormone receptors and can help to explain the link between hormonal factors and myofascial pain. It is known, in fact, that estrogen and relaxin play a key role in extracellular matrix remodeling by inhibiting fibrosis and inflammatory activities, both important factors affecting fascial stiffness and sensitization of fascial nociceptors." Free PMC Article

Fede C, Angelini A, Stern R et al 2018. Quantification of hyaluronan in human fasciae: variations with function and anatomical site. J Anat. [Jul 24 Epub ahead of print] "Recently, alterations in fascial gliding-like movement have been invoked as critical in the etiology of myofascial pain.... One of the key elements that underlies such fascial movement is hyaluronan (hyaluronic acid).... This study quantifies for the first time the hyaluronan content of human fascial samples obtained from a variety of anatomic sites. Here, we demonstrate that the average amount varies according to anatomic site, and according to the different kinds of sliding properties of the particular fascia. For example, the fascia lata has 35 μg of hyaluronan per gram of tissue, similar to that of the rectus sheath (29 μg g-1 ). However, the types of fascia adherent to muscle contain far less hyaluronan: 6 μg g-1 in the fascia overlying the trapezius and deltoid muscles. In the fascia that surrounds joints, the hyaluronan increases to 90 μg g-1 , such as in the retinacula of the ankle, where greater degrees of movement occur. Surprisingly, no significant differences were detected at any site as a function of age or sex...with the sole exception of the plantar fascia."

Feinberg, B. I. and R. A. Feinberg. 1998. Persistent pain after total knee arthroplasty: treatment with manual  therapy and trigger point injections.  J Musculoskel Pain 6(4):85-95.  

Feinberg T, Sambamoorthi U, Lilly C et al. 2017. Potential mediators between fibromyalgia and C-Reactive protein: Results from a large U.S. community survey. BMC Musculoskelet Disord. 218(1):294. This study checked the relationship between C-reactive protein in FM patients, assessing the possibility of a relationship of co-existing conditions, body mass index, mood and sleep impairments, and other factors that could contribute to a positive result in this test for inflammatory processes. They found that a significant number of patients with positive C-reactive protein test results had co-existing conditions or high body mass index that could cause a positive on this test. "Prospective research is needed to confirm this, and clarify the potential mediating influence of obesity and comorbid conditions on this relationship." Free Article

Feldman, R. D. and N. D. Schmidt.  1999.  Moderate dietary salt restriction increases vascular and systemic insulin resistance.  Am J Hypertens 12(6):643-7.

Feng B, La JH, Schwartz ES et al. 2012. Neural and neuro-immune mechanisms of visceral hypersensitivity in irritable bowel syndrome. Am J Physiol Gastrointest Liver Physiol. [Mar 8 Epub ahead of print]. "Irritable bowel syndrome (IBS) is characterized as 'functional' because a pathobiological cause is not readily apparent. Considerable evidence, however, documents that sensitizing pro-inflammatory and lipotoxic lipids, mast cells and their products, tryptases, enteroendocrine cells and mononuclear phagocytes and their receptors are increased in tissues of IBS patients with colorectal hypersensitivity. It is also clear from recordings in animals of the colorectal afferent innervation that afferents exhibit long-term changes in models of persistent colorectal hypersensitivity. Such changes in afferent excitability and responses to mechanical stimuli are consistent with relief of discomfort and pain in IBS patients, including relief of referred abdominal hypersensitivity, upon intra-rectal instillation of local anesthetic. In the aggregate, these experimental outcomes establish the importance of afferent drive in IBS, consistent with a larger literature with respect to other chronic conditions in which pain is a principal complaint (e.g., neuropathic pain, painful bladder syndrome, fibromyalgia). Accordingly, colorectal afferents and the environment in which these receptive endings reside constitute the focus of this review."

Fenton BW, Palmieri PA, Durner C et al. 2009.  Quantification of abdominal wall pain using pain pressure threshold algometry in patients with chronic pelvic pain.  Clin J Pain. 25(6):500-505.  Pressure algometry is a very useful tool for those who cannot palpate TrPs.  There was a 75% improvement in pressure point testing after treating abdominal wall TrPs.  The authors seem unaware of the explicit specifications of myofascial TrPs.  They also seem unaware that most chronic pelvic pain comes from TrPs in the pelvic floor and other related areas, although they are to be commended for their work confirming the ubiquity of abdominal wall TrPs.

Fernández-Carnero J, La Touche R, Ortega-Santiago R et al. 2010. Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders. J Orofac Pain. 24(1):106-112. “The application of dry needling into active TrPs in the masseter muscle induced significant increases in PPT (pressure pain threshold) levels and maximal jaw opening when compared to the sham dry needling in patients with myofascial TMD.”  [Treatment of related TrPs can significantly ease symptoms of TMJ, including pain and jaw restriction. It is essential that treatment be as prompt as possible to avoid unequal tension on the discs of the jaw. DJS]

Fernandez-Carnero J, Ge HY, Kimura Y.  2010. Increased spontaneous electrical activity at a latent myofascial trigger point after nociceptive stimulation of another latent trigger point. Clin J. Pain 26(2):138-143.  This groundbreaking paper shows how activity at a latent TrP in the infraspinus muscle may increase sensitivity and activity of a TrP in the forearm.  This study demonstrates both the formation of satellite TrPs and TrP cascades, showing a sensory connection between distant TrPs.  It also shows a decrease in sensitivity of the forearm TrP after the shoulder TrP was successfully treated.  [This is a critical paper. I hope it quiets critics who disbelieve in the formation of satellite TrPs and TrP cascades. Thank you, authors.  DJS]

Fernandez-Carnero J, Fernandez-de-Las-Penas C, de la Liave-Rincon AI et al. 2007.  Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia.  Clin J Pain. 23(4):353-360.  “Lower PPT (pressure pain threshold) and larger referred pain patterns suggest that peripheral and central sensitization exists in LE (lateral epicondamgia).”

Fernandez-de-Las-Penas C. 2015. Myofascial head pain. Curr Pain Headache Rep. 19(7):28. "Muscle nociception is mainly characterized by local tenderness and referred pain. The neurophysiological basis of muscle pain supports a role of sensitization mechanisms. From a clinical viewpoint, muscle pain is represented by the presence of myofascial trigger points (TrPs). Evidence suggests that TrPs are able to start a peripheral nociceptive mechanism and hence contributing to changes in the central nervous system. Several studies demonstrated that the referred pain elicited by TrPs reproduces the headache pattern in patients with tension-type headache (TTH), migraine, cervicogenic headache and, in some individuals, with cluster headache. In fact, sensitization of nociceptive pain pathways in the central nervous system due to prolonged nociceptive stimuli from TrPs seems to be responsible for the conversion of episodic to chronic TTH. In other headaches, TrPs may be able to stimulate the trigeminal nucleus caudalis and hence triggering a migraine or cluster headache attack. Proper treatment directed towards TrP inactivation has documented positive effects in individuals with these headaches; however, longitudinal studies are needed to further determine the role of TrPs in head pain."

Fernandez-de-las-Penas C. 2009. Interaction between trigger points and joint hypomobility: a clinical perspective. J Man Manip Ther. 17(2):74-77. "Reduction of joint mobility appears related to local muscles innervated from the segment, which suggests that muscle and joint impairments may be indivisible and related disorders in pain patients. …There is scientific evidence showing change in muscle sensitivity in muscle TrP after spinal manipulation, which suggests that clinicians should include treatment of joint hypomobility in the management of TrPs. Nevertheless, the order in which these muscle and joint impairments should be treated is not known and requires further investigation." [The intriguing hypotheses mentioned here did not include the possibility that muscle contracture caused by TrPs can torque the joint, provoking hypermobility in the opposite direction. It is to be hoped that more investigations on this interrelationship will be forthcoming. DJS]

Fernandez-de-las-Penas C. 2010. New evidence for trigger point involvement in tension-type headaches. J Musculoskel Pain. 18(4):354-360. "Tension-type headache (TTH) is the most common form of headache and its chronic form (chronic tension-type headache (CTTH)) is one of the most neglected and difficult headaches to treat. TTH is an overarching syndrome of 'featureless' headaches characterized by nothing but pain in the head….The term 'tension-type' has been chosen by the International Headache Society (ICHD-II) to offer a new heading underlining the uncertain pathogenesis, but indicating that some form of muscle tension may play a role….Hyperalgesic and allodynic responses support the role of both peripheral and central mechanisms in the development of the clinical picture of CTTH. In fact, it is suggested that central sensitization, a reduction in inhibitory pain mechanisms, and peripheral sensitization of muscle nociceptors are mechanisms involved in perceived pain in CTTH….Subjects who develop TTH have showed normal tenderness scores and pressure pain threshold levels before the beginning of the symptoms, which suggests that the mechanical hypersensitivity is rather a consequence than a risk factor for the development of TTH." "Previous studies have found that TTH patients described their head pain as pressing, tightening, or soreness. Dull and tight heaviness are also pain quality features of TTH attacks. These pain features resemble the descriptions of clinically referred pain elicited by TrPs as described by Simons et al." "Recent clinical studies have clearly demonstrated the relevance of active TrPs in CTTH. In fact, recent studies have described the referred pain elicited from two extra-ocular muscles, i.e., superior oblique and lateral rectus in patients with CTTH."

Fernandez-de-las-Penas C, Alonso-Blanco C, Del Amo-Perez A et al. 2007.  Trigger points in the masticatory muscles in subjects presenting with ankylosing spondylitis.  J Musculoskel Pain. 15(3):39-47.  “Trigger points in the masticatory muscles were more conspicuous in AS subjects than in HNCs.  Patients showed a reduced active mouth opening and cervical flexion-extension motion than matched HNCs.  The AS subjects with lesser mouth opening showed a greater occiput-to-wall distance and a greater number of TrPs in the masticatory muscles.”

Fernandez-de-Las-Penas C, Alonso-Blanco C, Luz Cuadrado M et al. 2006.  Myofascial trigger points in the suboccipital muscles in episodic tension-type headache.  Man Ther. 11(3):225-230.   

Fernandez-de-Las-Penas C, Alonso-Blanco C, Miangolarra JC. 2006.  Myofascial trigger points in subjects presenting with mechanical neck pain: a blinded, controlled study.  Man Ther. [Jun 10 Epub ahead of print]  “Active TrPs were more frequent in patients presenting with mechanical neck pain than in healthy subjects.”

Fernández-de-Las-Peñas C, Ambite-Quesada S, Gil-Crujera A et al. 2012. Catechol-O-Methyltransferase Val158Met Polymorphism Influences Anxiety, Depression, and Disability, but not Pressure Pain Sensitivity, in Women with Fibromyalgia Syndrome. J Pain. [Sep 28 Epub ahead of print]. "This study suggests that the Val158Met COMT polymorphism modulated some psychological variables but not pressure pain sensitivity in FMS because women with FMS carrying the Met/Met genotype exhibit higher disability, depression, and anxiety than but similar PPTs to those with Val/Met and Val/Val genotypes. This study provides further evidence of potential genetic factors that predispose women with FMS to exhibit the disease more severely."

Fernandez-De-Las-Penas C, Arendt-Nielsen L. 2017. Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert Rev Neurother. 26:1-7. "The underlying etiology of tension type headache (TTH) is not understood. The current paper highlights the etiologic role of muscle trigger points (TrPs) to the development and maintenance of central sensitization in TTH and its clinical repercussion for proper management of these patients…. Current literature suggests that the referred pain elicited by active trigger points (TrPs) contributes to the manifestations of TTH. There is also evidence supporting that TrPs represent a peripheral source of nociception and thereby a driver in the development of central sensitization. In fact, TrPs have been found to be associated with widespread pressure pain sensitivity in TTH."

Fernandez-de-Las-Penas C, Arendt-Nielsen L. 2016. Myofascial pain and fibromyalgia: two different but overlapping disorders. Pain Manag. [Jun 14 Epub ahead of print.] "There is good evidence supporting that people with fibromyalgia syndrome (FMS) exhibit central sensitization. The role of peripheral nociception is under debate in FMS. It seems that widespread pain experienced in FMS is considered multiple regional pains; therefore, several authors proposed that muscles play a relevant role in FMS. Trigger points (TrPs) have long been a contentious issue in relation to FMS. Preliminary evidence reported that the overall spontaneous pain is reproduced by referred pain from active TrPs, suggesting that FMS pain is largely composed of pain arising, at least partially, from TrPs. Finally, there is preliminary evidence suggesting that management of TrPs is able to modulate the CNS and is effective for reducing pain in FMS, although results are conflicting and future studies are clearly needed."

Fernandez-de-las-Penas C, Carratala-Tejada M, Luna-Oliva L et al. 2006.  The immediate effect of hamstring muscle stretching in subjects’ trigger points in the masseter muscle.  J Musculoskel Pain 14(3):27-35.  “The present study demonstrated an increase in active mouth opening and a decrease in TrP sensitivity in the masseter muscle in response to the stretch of the hamstring muscles.”  Treatment, and constriction, in the myofascia of one area can significantly alter the myofascia in another area, even long distance.

Fernandez-de-Las-Penas C, Cleland J, Palacios-Cena M et al. 2017. Effectiveness of manual therapy versus surgery in pain processing due to carpal tunnel syndrome: A randomized clinical trial. Eur J Pain. [Mar 14 Epub ahead of print.] "People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of manual therapy versus surgery for improving pain and nociceptive gain processing in people with CTS…. Results: At 12 months, 95 women completed the follow-up. Patients receiving manual therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months…and higher decrease of pain intensity at 3 month follow-up… than those receiving surgery. No significant differences were observed between groups for the remaining outcomes."

Fernandez-de-las-Penas C, Cleland JA, Cuadrado ML et al. 2008.  Predictor variables for identifying patients with chronic tension-type headache who are likely to achieve short-term success with muscle trigger point therapy.  Cephalalgia. 28(3):264-275.  “The present CPR (clinical prediction rule) provides the potential to identify CTTH (chronic tension-type headache) patients who are likely to experience short-term and 1-month follow-up success...” with manual TrP therapy.

Fernandez-de-Las-Penas C, Cleland JA, Palomeque-Del-Cerro L et al. 2010. Development of a clinical prediction rule for identifying women with tension-type headache who are likely to achieve short-term success with joint mobilization and muscle trigger point therapy. Headache Nov 4 [Epub ahead of print] The current clinical prediction rule may allow clinicians to make an a priori identification of women with TTH who are likely to experience short-term self-report improvement with a multimodal session including joint mobilization and TrP therapies."

Fernandez-de-Las-Penas C, Cleland JA, Ortega-Santiago R et al. 2010. Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy. Exp Brain Res. 207(1-2):85-94. "The physical therapy sessions included both soft tissue mobilization directed at the anatomical sites of potential median nerve entrapment and a passive nerve slider neurodynamic technique targeted to the median nerve.... Our results support that widespread central sensitization may not be present in women with CTS who are likely to achieve a successful outcome with physical therapy."

Fernandez-de-Las-Penas C, Courtney CA. 2014. Clinical reasoning for manual therapy management of tension type and cervicogenic headache. J Man Manip Ther. 22(1):44-50. "In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches."

Fernandez-de-Las-Penas C, Cuadrado M, Arendt-Nielsen L et al. 2007.  Myofascial trigger points and sensitization: an updated pain model for tension-type headache.  Cephalalgia [Mar 14 Epub ahead of print]   “Based on available data, an updated pain model for CTTH is proposed in which headache can at least partly be explained by referred pain from TrPs in the posterior cervical, head and shoulder muscles.  In this updated pain model, TrPs would be the primary hyperalgesic zones responsible for the development of central sensitization in CTTH.”

Fernandez-de-las-Penas C, Cuadrado M, Pareja J. 2007.  Referred pain from extra-ocular muscle trigger points in chronic headache.  J Musculoskel Pain 15 (Supp 13):19 item 27.  [Myopain 2007 Poster]   “Nociceptive inputs from the extra-ocular muscles may provoke a continuous afferent bombardment to the trigeminal nerve nucleus caudalis in CTTH (chronic tension-type headache).  The prolonged nociceptive activation by such muscle inputs might contribute to central sensitization.”  [This exciting research indicates that even constant pain from facial muscles around the eye could be enough to contribute to body-wide central nervous system sensitization. DJS]

Fernandez-de-Las-Penas C, Cuadrado M, Pareja J. 2006.  Myofascial trigger points, neck mobility and forward head posture in unilateral migraine.  Cephalalgia. 26(9):1061-1070.  “Active TrPs located ipsilateral to migraine headaches might be a contributing factor in the initiation or perpetuation of migraine.”

Fernandez de las Penas C, Cuadrado ML, Gerwin RD et al. 2005.  Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle.  Headache. 45(6):731-737.  “This pain was perceived as a deep ache located at the retro-orbital region, sometimes extending to the supra-orbital region or the homo-lateral forehead.  Pain intensity was greater in CTTH (chronic tension-type headache) patients than in ETTH (episodic tension-type headache) patients or control subjects (P<.001)...  MTrPs in the SOM (superior oblique muscle) may evoke a typical referred pain pattern in patients with TTH (tension-type headache).  The presence of a myofascial disorder in the trochlear region might contribute to the pathogenesis of TTH.”  [It is with gratitude that I post this confirmation of the extrinsic eye TrPs mentioned in my books, and I hope to see much more work from this excellent team. DJS]

Fernandez-de-las-Penas C, Cuadrado ML, Pareja JA. 2007. Muscle atrophy of the suboccipital muscles associated with active trigger points in chronic tension type headache.  J Musculoskel Pain 15 (Supp 13):19 item 28.  [Myopain 2007 Poster]  “Muscle atrophy in the RCPmin, but not in the RCPmaj, was associated to active TrPs in the suboccipital muscles in CTTH.  Nociceptive inputs originated in active TrPs might contribute to a greater muscle atrophy of the involved muscles.”  [This study is interesting in that it suggests that pain from MTPs could contribute to muscle atrophy.  As MTPs can cause nerve entrapment and blood vessel entrapment, this would be logical. DJS]

Fernandez-de-las-Penas C, De-la-Llave-Rincon A, Miangolarra J. 2007.  Uncommon referred pain from scalene muscle trigger points in chronic tension type headache.  J Musculoskel Pain 15 (Supp 13):21 item 31.  [Myopain 2007 Poster]  “Nine CTTH (chronic tension type headache) patients had an uncommon referred pain pattern from scalene muscle TrPs, so these headache patients may need examination for scalene TrPs.  It is known that CTH show sensitization of central pathways, which may provoke larger referred pain areas of active muscle TrPs.  Further, there are examples of neurologically related exceptional pain patterns in other muscles [e.g. the soleus].”  [I believe that this is not so uncommon, and I have seen it several times before, but it may be more common in patients with CMP and central sensitization. DJS]

Fernandez-de-Las-Penas C, Dommerholt J. 2017. International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain Med. [Aug 22 Epub ahead of print] "There is no consensus on the essential diagnostic criteria for diagnosing a trigger point (TrP). In fact, a variety of diagnostic criteria are currently being used. Our aim was to conduct a Delphi panel to achieve an international consensus on the cluster of criteria needed for the TrP diagnosis to reach a consensus on the definition of active and latent TrPs and to clarify different clinical considerations about TrPs….Following international guidelines, an international three-round Delphi survey was conducted. Questions were created based on a systematic literature search of the diagnostic criteria for TrPs….Sixty experts from 12 countries completed all rounds of the survey. A cluster of three diagnostic criteria was proposed as essential for the TrP diagnosis: a taut band, a hypersensitive spot, and referred pain. Eighty percent of the experts agreed that the referred pain elicited by a TrP can include different sensory sensations and not just pain, that is, pain spreading to a distant area, deep pain, dull ache, tingling, or burning pain. Eighty-four percent of the international experts consistently answered that the main clinical differences between active and latent TrPs are the reproduction of any of the symptoms experienced by a patient and the recognition of pain. No specific location of the pain referral area and TrP location should be expected….This Delphi panel has produced an expert-based standardized definition of a TrP with a discussion of the clinical components, including the definition of referred pain and the difference between active and latent TrPs, thereby providing a foundation for future research in MPS."

Fernandez-de-Las-Penas C, Dommerholt J. 2014. Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep. 16(1):395. "Trigger points (TrP) are hyperirritable spots in a taut band of a skeletal muscle, which usually have referred pain. There is controversy over whether TrP are a peripheral or central nervous system phenomenon. Referred pain, the most characteristic sign of TrP, is a central phenomenon initiated and activated by peripheral sensitization, whereby the peripheral nociceptive input from the muscle can sensitize dorsal horn neurons that were previously silent. TrP are a peripheral source of nociception, and act as ongoing nociceptive stimuli contributing to pain propagation and widespread pain. Several studies support the hypothesis that TrP can induce central sensitization, and appropriate TrP treatment reduces central sensitization. In contrast, preliminary evidence suggests that central sensitization can also promote TrP activity, although further studies are needed. Proper TrP management may prevent and reverse the development of pain propagation in chronic pain conditions, because inactivation of TrP attenuates central sensitization."

Fernandez-de-Las-Penas C, Falla D, Palacios-Ceña M, Fuensalidad-Novo S et al. 2017. Perceived pain extent is not associated with widespread pressure pain sensitivity, clinical features, related-disability, anxiety, or depression in women with episodic migraine. Clin J Pain. [Jul 20 Epub ahead of print] "People with migraine present with varying pain extent and an expanded distribution of perceived pain may reflect central sensitization… No significant associations were observed between pain extent and PPTs in trigeminal, extra-trigeminal or distant pain-free areas, migraine pain features, or psychological variables including anxiety or depression and migraine related-disability."

Fernandez-de-las-Penas C, Fernandez-Carnero J, Miangolarra J. 2007.  Multifidus muscle trigger point management and stabilizing exercises in low back pain.  J Musculoskel Pain 15 (Supp 13):21 item 32.  [Myopain 2007 Poster]  “In some CLBP (chronic low back pain) patients, it would be necessary to treat lumbar multifidus TrPs before starting a stability exercise program because it includes voluntary contraction of this muscle.  Nociceptive barrage originated in active TrPs could act as a contributing factor for muscle inhibition.”  [Multifidi, especially with nerve entrapment, is exceedingly common in patients with CMP and central sensitization.   Treatment of the nerve pain is before the TPM will increase the efficacy of the TPM treatment. DJS]

Fernandez-de-las-Penas C, Fernandez-Mayoralas DM, Ortega-Santiago R et al. 2011. Referred pain from myofascial trigger points in head, neck and shoulder muscles reproduces head pain features in children with chronic tension type headache. J Headache Pain. 12(1):35-43. TrPs are a common cause of chronic tension type headaches in children. [Pediatricians must become aware of this fact, and be trained in diagnosis and treatment of TrPs. DJS]

Fernandez-de-Las-Penas C, Fernández-Munoz JJ, Navarro-Pardo E et al. 2016. Identification of subgroups of women with carpal tunnel syndrome with central sensitization. Pain Med. [Apr 10 Epub ahead of print.] "This study showed that a clinical prediction rule originally developed for identifying women with CTS who are likely to respond favorably to manual physical therapy was able to identify women exhibiting higher widespread pressure hyper-sensitivity and thermal hyperalgesia. This subgroup of women with CTS exhibiting higher sensitization may need specific therapeutic programs."

Fernandez-de-Las-Penas C, Galan-Del-Rio F, Alonso-Blanco C et al. 2010. Referred pain from muscle trigger points in the masticatory and neck-shoulder musculature in women with temporomandibular disorders. J Pain. [May 20 Epub ahead of print]. “The current study showed the existence of multiple active muscle TrPs in the masticatory and neck-shoulder muscles in women with myofascial TMD pain. The local and referred pain elicited from active TrPs reproduced pain complaints in these patients. Further, referred pain areas were larger in TMD pain patients than in healthy controls. The results are also in accordance with the notion of peripheral and central sensitization mechanisms in patients with myofascial TMD.” [Another paper showing the association of TrPs and the central sensitization of FM. DJS]

Fernandez-de-Las-Penas C, Ge HY, Arendt-Nielsen L et al. 2006.  Referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache.  Eur J Pain. [Aug 17 Epub ahead of print]  Patients with chronic tension type headache may have spatial summation of perceived pain and mechanical pain, with referral pain characteristics of myofascial TrPs.

Fernandez-de-las-Penas C, Grobli C, Ortega-Santiago R et al. 2012. Referred pain from myofascial trigger points in head, neck, shoulder, and arm muscles reproduces pain symptoms in blue-collar (manual) and white-collar (office) workers. Clin J Pain. 28(6):511-518. "Blue-collar and white-collar workers exhibited a similar number of TrPs in the upper quadrant musculature. The referred pain elicited by active TrPs reproduced the overall pain pattern. The distribution of TrPs was not significantly different between groups. Clinicians should examine for the presence of muscle TrPs in blue-collar and white-collar workers." [TrPs are common in people no matter what type of work they do. DJS]

Fernández-de-Las-Peñas C, Madeleine P, Martínez-Perez A. 2010. Pressure pain sensitivity topographical maps reveal bilateral hyperalgesia of the hands in patients with unilateral carpal tunnel syndrome. Arthritis Care Res (Hoboken). [Mar 16 Epub ahead of print]. “Our findings revealed bilateral generalized pressure pain hyperalgesia in unilateral CTS (carpal tunnel syndrome) since lower PPT (pressure pain threshold) levels were found in all the points. The pressure pain hyperalgesia was not uniformly distributed since PPTs were lower in points over the proximal phalanx of the fingers and the thenar eminency as compared to those points located over the distal phalanx of the fingers. The decrease in PPT levels was associated with the intensity and the duration of the pain symptoms supporting a role of both peripheral and central sensitization mechanisms in this pain condition.”  [TrPs are frequently the cause of symptoms described as “carpal tunnel.”  It is essential to find the cause of the pain and treat that as soon as possible, so that surgery can be avoided. DJS]

Fernandez-de-Las-Penas C, Ortega-Santiago R, Cuandrado ML et al. 2010. Bilateral widespread mechanical pain hypersensitivity as a sign of central sensitization in patients with cluster headaches. Headache Nov 4 [Epub ahead of print] Pain hypersensitivity was global, including tibialis (calf muscle), in chronic headache patients. "Our findings revealed bilateral widespread pressure pain hypersensitivity in patients with CH confirming the presence of central sensitization mechanisms in this headache condition." [Chronic headache, even from TrPs, can lead to a central sensitization state such as fibromyalgia. DJS]

Fernandez-de-Las-Penas C, Penacoba-Puente C, Cigaran-Mendez M et al. 2014. Has catechol-O-methyltransferase genotype (Val158Met) an influence on endocrine, sympathetic nervous and humoral immune systems in women with fibromyalgia syndrome? Clin J Pain. 30(3):199-204. "Stress can play an important role in etiology of fibromyalgia syndrome (FMS) by activating the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic nervous system (SNS), and altering the immune system. The current study examined the influence of catechol-O-methyltransferase (COMT) Val158Met genotypes on salivary markers of HPA axis (cortisol), SNS (α-amylase), and immune (IgA) systems in women with FMS….The results suggest that women with FMS with the Met/Met genotype exhibit greater disturbed activity of the SNS and humoral immune system. These results provide initial evidence of a link between Val158Met polymorphism and dysfunctions in the SNS and humoral immune system in women with FMS."

Fernandez-de-las-Penas C, Perez-de-Heredia-Torres M, Miangolarra J. 2007.  Trigger point management in lateral epicondylalgia.  J Musculoskel Pain 15 (Supp 13):20 item 29.  [Myopain 2007 Poster]  “Referred pain from TrPs in these patients was causing the usual pain reported by patients with lateral epicondylalgia.  Muscle tension provoked by TrP taut band may play an important role in the genesis and relief of the pain commonly seen in lateral epicondylalgia.”

Fernandez de las Penas CF, Carnero JF, Page JCM. 2005.  Musculoskeletal disorders in mechanical neck pain: myofascial trigger points versus cervical joint dysfunction – a clinical study.  J Musculoskeletal Pain 13(1).  “There is a possible relationship between the presence of TrPs in the upper trapezius muscle and the presence of cervical dysfunctions at C3 and C4 vertebrae in patients suffering from mechanical neck pain.  However, it cannot be established as a cause-effect relationship.  Moreover, there is clinical evidence showing that joint dysfunctions can induce TrP activity, and that TrP activity can aggravate corresponding joint dysfunction.”

Fernandez-Lao C, Cantarero-Villanueva I, Fernandez-de-Las-Penas C et al. 2010. Myofascial Trigger Points in Neck and Shoulder Muscles and Widespread Pressure Pain Hypersensitivity in Patients with Postmastectomy Pain: Evidence of Peripheral and Central Sensitization. Clin J Pain. [Sep 8 Epub ahead of print]. "Our findings revealed bilateral widespread pressure pain hypersensitivity in patients with postmastectomy pain. In addition, the local and referred pain elicited by active TrPs reproduced neck and shoulder/axillary complaints in these patients. These results suggest peripheral and central sensitization in patients with postmastectomy pain." [Other research has found evidence of TrPs causing post-surgical pain. This also indicates that the TrPs are at least contributing, and possibly causing, the development of hypersensitivity in other areas. This is one way central sensitization can develop. DJS]

Fernández-Pérez AM, Villaverde-Gutiérrez C, Mora-Sánchez A et al. 2012. Muscle trigger points, pressure pain threshold, and cervical range of motion in patients with high level of disability related to acute whiplash injury. J Orthop Sports Phys Ther. 42(7):634-641. This study was created to..."analyze the differences in the prevalence of trigger points (TrPs) between patients with acute whiplash-associated disorders (WADs) and healthy controls, and to determine if widespread pressure hypersensitivity and reduced cervical range of motion are related to the presence of TrPs in patients with acute WADs....Patients had significantly lower PPTs (pressure pain threshold) in all tested locations and less active cervical range of motion than controls.... In the patient group, there were significant negative correlations between the number of active TrPs and PPT over the C5-C6 joints and cervical range of motion in flexion, extension, and rotation in both directions: the greater the number of active TrPs, the lower the bilateral PPT over the neck and the greater the cervical range of motion limitation....The local and referred pain elicited from active TrPs reproduced neck and shoulder pain patterns in individuals with acute WADs with higher levels of disability. Patients with acute WADs exhibited widespread pressure hypersensitivity and reduced cervical mobility. The number of active TrPs was related to higher neck pain intensity, the number of days since the accident, higher pressure pain hypersensitivity over the cervical spine, and reduced active cervical range of motion."

Ferracini GN, Florencio LL, Dach F et al. 2017. Myofascial trigger points and migraine-related disability in women with episodic and chronic migraine. Clin J Pain. 33(2):109-115. "The aim of this study was to investigate the differences in the presence of head and neck-shoulder trigger points (TrPs) between women with episodic or chronic migraine and their association with migraine-related disability.....Women with episodic and chronic migraine had a similar number of TrPs. TrPs may be considered a trigger factor that can facilitate the onset of migraine or also can potentially be a promoting factor for pain once the migraine attack has started and hence may contribute to related disability. Nevertheless, we observed that the number of TrPs in the head and neck-shoulder muscles in an interictal state was not associated with the degree of migraine-related disability, suggesting a multifactorial nature of self-perceived disability in this population."

Ferrari R. 2012. Quantitative assessment of the "inexplicability" of fibromyalgia patients: a pilot study of the fibromyalgia narrative of "medically unexplained" pain. Clin Rheumatol. [Jul 22 Epub ahead of print]. "Compared to other patients with chronic, widespread pain, fibromyalgia patients report a much greater degree of difficulty in understanding the cause of their pain and explaining the cause of their pain to others. This phenomenon may reflect the narrative of 'inexplicability' in fibromyalgia patients that distinguishes them from other widespread pain populations."

Ferre A. 2016. Chronic fatigue syndrome and sleep disorders: clinical associations and diagnostic difficulties. Neurologia. [Feb 11 Epub ahead of print]. [Article in English, Spanish]. "Chronic fatigue syndrome (CFS) is characterized by the presence of intractable fatigue and non-restorative sleep, symptoms which are also very prevalent in multiple diseases and appear as side effects of different drugs. Numerous studies have shown a high prevalence of sleep disorders in patients with CFS. However, non-restorative sleep and fatigue are frequently symptoms of the sleep disorders themselves, so primary sleep disorders have to be ruled out in many cases of CFS….Identifying primary sleep disorders in patients meeting diagnostic criteria for CFS will allow for a more comprehensive treatment approach involving new diagnostic and therapeutic strategies that may improve quality of life for these patients." Free Article

Ferrer-Pena R, Munoz-García D, Calvo-Lobo C et al. 2018. Pain expansion and severity reflect central sensitization in primary care patients with greater trochanteric pain syndrome. Pain Med. [Oct 11 Epub ahead of print] "Conditioned pain modulation (CPM), pain location, temporal summation, pressure pain detection threshold (PPDT), and pain intensity were recorded. Pain severity was determined with the Graded Chronic Pain Scale (GCPS)....Patients with GTPS presented altered CPM, a relationship with more pain areas associated with negative CPM, and a positive association between pain severity and mechanical hyperalgesia at remote sites. Thus, physicians could apply these outcome measurements to assess primary care patients with GTPS and determine the central sensitization presence...."

Fetler L, Amigorena S. 2005.  Neuroscience.  Brain under surveillance: the microglia patrol.  Science 309(5733):392-393.  Opioids can activate pain inhibitory and facilitatory systems, but opioid-induced hyperalgesia may be prevented by strategies such as concomitant administration of NSAIDS or NMDA antagonists, use of combinations of opioids with different receptor selectivity, and other methods.

Field T. 2016. Massage therapy research review. Complement Ther Clin Pract. 24:19-31. "In this review, massage therapy has been shown to have beneficial effects on varying conditions including prenatal depression, preterm infants, full-term infants, autism, skin conditions, pain syndromes including arthritis and fibromyalgia, hypertension, autoimmune conditions including asthma and multiple sclerosis, immune conditions including HIV and breast cancer and aging problems including Parkinson's and dementia. Although many of the studies have involved comparisons between massage therapy and standard treatment control groups, several have compared different forms of massage (e.g. Swedish versus Thai massage), and different active therapies such as massage versus exercise. Typically, the massage therapy groups have experienced more positive effects than the control or comparison groups. This may relate to the massage therapy providing more stimulation of pressure receptors, in turn enhancing vagal activity and reducing cortisol levels. Some of the researchers have assessed physical, physiological and biochemical effects, although most have relied exclusively on self-report measures. Despite these methodological problems and the dearth of research from the U.S., the massage therapy profession has grown significantly and massage therapy is increasingly practiced in traditional medical settings, highlighting the need for more rigorous research."

Field T. Massage therapy research review. Complement Ther Clin Pract. 2014 [Aug 1 Epub ahead of print.] "When moderate and light pressure massage have been compared in laboratory studies, moderate pressure massage reduced depression, anxiety and heart rate, and it altered EEG patterns, as in a relaxation response. Moderate pressure massage has also led to increased vagal activity and decreased cortisol levels. Functional magnetic resonance imaging data have suggested that moderate pressure massage was represented in several brain regions including the amygdala, the hypothalamus and the anterior cingulate cortex, all areas involved in stress and emotion regulation. Further research is needed to identify underlying neurophysiological and biochemical mechanisms associated with moderate pressure massage."

Field T, Diego M, Cullen C et al. 2002. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy.  J Clin Rheumatol. 8(2):72-76.

Field T, Hernandez-Reif M, Diego M et al. 2007.  Lower back pain and sleep disturbance are reduced following massage therapy.  J Bodywork Move Ther. 11, 141-145.  “…the massage therapy group, as compared to the relaxation group, reported experiencing less pain, depression, anxiety and sleep disturbance.  They also showed improved trunk and pain flexion performance.”

Fields RD, Araque A, Johansen-Berg H et al. 2013. Glial Biology in Learning and Cognition. Neuroscientist. 2013 Oct 11. [Epub ahead of print] "Neurons are exquisitely specialized for rapid electrical transmission of signals, but some properties of glial cells, which do not communicate with electrical impulses, are well suited for participating in complex cognitive functions requiring broad spatial integration and long-term temporal regulation. Astrocytes, microglia, and oligodendrocytes all have biological properties that could influence learning and cognition. Myelination by oligodendrocytes increases conduction velocity, affecting spike timing and oscillations in neuronal activity. Astrocytes can modulate synaptic transmission and may couple multiple neurons and synapses into functional assemblies. Microglia can remove synapses in an activity-dependent manner altering neural networks. Incorporating glia into a bicellular mechanism of nervous system function may help answer long-standing questions concerning the cellular mechanisms of learning and cognition."

Fikree A, Aktar R, Grahame R. 2015. Functional gastrointestinal disorders are associated with the joint hypermobility syndrome in secondary care: a case-control study. Neurogastroenterol Motil. 27(4):569-579. "JHS (joint hypermobility syndrome) is significantly associated with FGID functional gastrointestinal disorders, and this subgroup of patients has increased comorbidity and decreased QOL (quality of life). Further research is required to understand the pathophysiological basis of this association."

Fikree A, Grahame R, Aktar R et al. 2014. A Prospective Evaluation of Undiagnosed Joint Hypermobility Syndrome in Patients with Gastrointestinal Symptoms. Clin Gastroenterol Hepatol. [Jan 15 Epub ahead of print.] "Many upper and lower GI symptoms increased with increasing severity of JHS phenotype. Upper GI symptoms were dependent on autonomic and chronic pain factors. JHS is common in GI clinics, with increased burden of upper GI and extraintestinal symptoms and poorer quality of life. Recognition of JHS will facilitate multidisciplinary management of GI and extra-GI manifestations."

Filipovic V, Viskic-stalec N. 2006.  The mobility capabilities of persons with adolescent idiopathic scoliosis.  Spine. 31(19):2237-2242.  When there is a lack of normal mobility functions, especially with weak postural control mechanisms and proprioception, the body compensates and scoliosis can result.

Fillingim RB, Bruehl S Dworkin RH et al. 2014. The ACTTION-American Pain Society Pain Taxonomy (AAPT): An Evidence-Based and Multidimensional Approach to Classifying Chronic Pain Conditions. J Pain. 15(3):241-249. "Current approaches to classification of chronic pain conditions suffer from the absence of a systematically implemented and evidence-based taxonomy. Moreover, existing diagnostic approaches typically fail to incorporate available knowledge regarding the biopsychosocial mechanisms contributing to pain conditions. To address these gaps, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration and the American Pain Society (APS) have joined together to develop an evidence-based chronic pain classification system called the ACTTION-APS Pain Taxonomy. This paper describes the outcome of an ACTTION-APS consensus meeting, at which experts agreed on a structure for this new taxonomy of chronic pain conditions. Several major issues around which discussion revolved are presented and summarized, and the structure of the taxonomy is presented. ACTTION-APS Pain Taxonomy will include the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. In coming months, expert working groups will apply this taxonomy to clusters of chronic pain conditions, thereby developing a set of diagnostic criteria that have been consistently and systematically implemented across nearly all common chronic pain conditions. It is anticipated that the availability of this evidence-based and mechanistic approach to pain classification will be of substantial benefit to chronic pain research and treatment….The ACTTION-APS Pain Taxonomy is an evidence-based chronic pain classification system designed to classify chronic pain along the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors."

Fillingim RB, Gear RW. 2004.  Sex differences in opioid analgesia: clinical and experimental findings. Eur J Pain 8(5):413-425.

Finan PH, Quartana PJ, Smith MT. 2015. The effects of sleep continuity disruption on positive mood and sleep architecture in healthy adults. SLEEP 38(11):1735–1742. "The purpose of this study was to test an experimental model of the effects of sleep continuity disturbance on sleep architecture and positive mood in order to better understand the mechanisms linking insomnia and depression…. To our knowledge, this is the first human experimental study to demonstrate that, despite comparable reductions in total sleep time, partial sleep loss from sleep continuity disruption is more detrimental to positive mood than partial sleep loss from delaying bedtime, even when controlling for concomitant increases in negative mood. With these findings, we provide temporal evidence in support of a putative biologic mechanism (slow wave sleep deficit) that could help explain the strong comorbidity between insomnia and depression."

Fine PG. 1987. Myofascial trigger point pain in children.  J Pediatr. 111(4):547-548. 

Fine PG, Milano R, Hare BD. 1988.  The effects of myofascial trigger point injections are naloxone reversible.  Pain. 32(1):15-20.  “These results demonstrate a naloxone-reversible mechanism in TPI (trigger point injection) therapy.  This suggests an endogenous opioids system as a mediator for the decreased pain and improved physical findings following injection...” of TrPs with local anesthetic.

Fine, PG. 1987.  Myofascial trigger point pain in children.  J Pediatr.111(4):547-548.  This article is noteworthy in that it misidentified myofascial pain syndrome as part of fibromyalgia.  This is too common a mistake.  It does encourage early diagnosis and treatment, but to do that doctors will have to know which condition – or both – are involved.

Firmani M, Miralles R, Casassus R. 2014. Effect of lidocaine patches on upper trapezius EMG activity and pain intensity in patients with myofascial trigger points: A randomized clinical study. Acta Odontol Scand. 1-9. "These clinical and EMG results support the use of 5% lidocaine patches for treating patients with MTrP of the upper trapezius muscle."

Fischer MJ, Horvath G, Krismer M et al. 2018. Evaluation of mitochondrial function in chronic myofascial trigger points - a prospective cohort pilot study using high-resolution respirometry. BMC Musculoskelet Disord. 19(1):388. "Myofascial trigger points (MTrPs) are...possibly related to mitochondrial impairment. They can result in pain and hypoxic areas within the muscle....This pilot study used a safe and minimally invasive technique for obtaining biopsies from MTrPs suitable for high-resolution respirometry analysis of mitochondrial function. The results suggest that there are no qualitative differences in mitochondrial function of MTrPs of the trapezius and gluteus medius muscles compared to the vastus lateralis control muscle, implying that alterations of mitochondrial function do not appear to have a role in the development of MTrPs."

Fischer S, Doerr JM, Strahler J et al. 2015. Stress exacerbates pain in the everyday lives of women with fibromyalgia syndrome - The role of cortisol and alpha-amylase. Psychoneuroendocrinology. 63:68-77. We tested whether and how stress and pain are intertwined in participants with FMS. We additionally examined the role of the two major stress-responsive systems, the hypothalamic-pituitary-adrenal axis and the autonomic nervous system, as potential mediators of this relationship…Stress seems to be a powerful exacerbating factor for pain as experienced by patients with FMS in their everyday lives. Cortisol may be involved in the diurnal fluctuation of pain levels in patients with FMS. Future studies should identify relevant daily stressors in persons with FMS and scrutinize the mechanisms underlying the cortisol-pain relationship.

Fischer S, Markert C, Strahler J et al. 2018. Thyroid functioning and fatigue in women with functional somatic syndromes - Role of early life adversity. Front Physiol. 9:564. "Fatigue is a core feature of functional somatic syndromes (FSS). Fatigue is also prominent in patients with thyroid diseases, which is unsurprising given the role of the hypothalamic-pituitary-thyroid (HPT) axis in regulating physiological energy demands. Research in healthy women has shown that early life adversity is linked with alterations in the HPT axis. In view of the substantial prevalence of early life adversity in patients with FSS, our aim was to investigate whether HPT functioning is related to (a) fatigue, and (b) early life adversity in these patients.... Conclusion: The lower TSH and the higher fT4, the more fatigue was reported by patients with FSS. In addition, lower TSH was linked with more early life adversity. Larger, prospective studies are warranted to determine whether HPT functioning may be a mediating pathway between early life adversity and fatigue in FSS." [This result may be due to the coexisting thyroid resistance. DJS]

Fishbain DA 1, Cole B, Lewis JE et al. 2014. What is the evidence that neuropathic pain is present in chronic low back pain and soft tissue syndromes? An evidence-based structured review. Pain Med. 15(1):4-15. "There is consistent evidence by all methods that NP (neuropathic pain) is present in CLBP and STS. Reported prevalence percentages by all methods are substantial. This has significant implications for the treatment of CLBP and STS."

Fishbain DA, Lewis JE, Cole B et al. 2006.  Lidocaine 5% patch: an open-label naturalistic chronic pain treatment trial and prediction of response.  Pain Med. 7(2):135-142.  This article shows some parameters in predicting the use of lidocaine patch response.  [There is also the necessity to locate the main pain generators.  If someone has a spinal abnormality instigating the TrPs or central sensitization, an articular area that is causing a TrP cascade or central sensitization, or one or two primary TrPs that are setting off others, then the lidocaine patch(es) could be very helpful.  If there are TrPs all over, or diffuse pain with no specific instigator that has been found, the patch may not be a good choice.  One to three patches may be used, and only for 12 hours at a time, with a 12 hour break.  The patient may have to make the choice of being able to sleep, if pain is causing unrestorative sleep or wakefulness, or being able to function during the day. DJS]

Fishbain DA, Cutler RB, Rosomoff HL et al.  2000.  Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain.  Pain Med. 1(4):332-339.  Clonazepam may help some myofascial pain.

Fishbain DA, Lewis JE, Cole B et al. 2006.  Lidocaine 5% patch: an open-label naturalistic chronic pain treatment trial and prediction of response.  Pain Med. 7(2):135-142.  This article shows some parameters in predicting the use of lidocaine patch response.  [There is also the necessity to locate the main pain generators.  If someone has a spinal abnormality instigating the TrPs or central sensitization, an articular area that is causing a TrP cascade or central sensitization, or one or two primary TrPs that are setting off others, then the lidocaine patch(es) could be very helpful.  If there are TrPs all over, or diffuse pain with no specific instigator that has been found, the patch may not be a good choice.  One to three patches may be used, and only for 12 hours at a time, with a 12 hour break.  The patient may have to make the choice of being able to sleep, if pain is causing unrestorative sleep or wakefulness, or being able to function during the day. DJS]

Fishman SM. 2006.  The role of the pain psychologist, trigger point injections, reflex sympathetic dystrophy.  J Pain Palliat Care Pharmacother. 20(4):93-97.  “This feature presents information for patients in a question and answer format.  It is written to simulate actual questions that many pain patients ask and to provide answers in a context and language that most pain patients will comprehend.  Issues addressed in this issue are the role of the pain psychologist, trigger point injections, and reflex sympathetic dystrophy.”

Fishman SM, Mahajan G, Jung SW et al. 2002.  The trilateral opioid contract.  Bridging the pain clinic and the primary care physician through the opioid contract.  J Pain Symptom Manage. 24(3):335-344. “We have extended the traditional use of opioid contracts to involve the primary care physician (PCP).  The PCP was asked to collaborate with the pain specialist’s decision to use opioids by cosigning an opioid contract.  Explicit in the agreement was the understanding that the primary care physician would assume prescribing the refills for these medications once the opioid regimen had become stabilized.  In all cases in which a contract was completed, the patient successfully stabilized on an appropriate opioid regimen and then discharged to the care of the PCP for long-term opioid treatment.  The opioid contract made an effective tool for networking specialty and primary care services in…chronic opioid therapy.”  [Too often the physician is neglected as part of the contract, and very often the pain is vastly undertreated.]

Fitzcharles M.A., Boulos P. 2003.  Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals.  Rheumatology (Oxford) 42(2):263-7.  “At the final evaluation the accuracy of the diagnosis regarding FM by either the referring physician or by the rheumatologist at the time of the initial visit was correct in 34% of patients.”  This finding may help explain the current high rates of FM and caution physicians to consider other diagnostic possibilities when addressing diffuse musculoskeletal pain.

Fitzcharles, M. A. and J. M. Esdaile. 1997. The overdiagnosis of fibromyalgia syndrome. Am J Med 103(1):44-50.

Fitzcharles MA, Perrot S, Hauser W.2018. Comorbid fibromyalgia: a qualitative review of prevalence and importance. Eur J Pain. May 26. [Epub ahead of print] "Fibromyalgia (FM) may be an unrecognized cause of suffering for persons with an array of medical conditions. This is especially true for illness that is characterized by pain of any nature. Once believed to be a unique diagnosis, FM is recently reported to occur concomitantly with various rheumatic diseases, and importantly adversely impacts global health status. However there is increasing report of FM associated with other diseases that are not defined by chronic pain." This review found: "Comorbid FM adversely affects both health status and outcome for rheumatic diseases, but with limited study in other diseases....When unrecognized, comorbid FM may be mistaken as poor control of the primary disease, leading to incorrect treatment decisions. FM may be a neglected condition that pervades many conditions and may contribute to the burden of illness. Physicians should be alert to the possibility of comorbid FM, and symptoms of FM should be specifically addressed." FM is NOT an illness of exclusion.

Fitzcharles MA, Ste-Marie PA, Goldenberg DL et al. 2013. Canadian guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 18(3):119-126.

Fitzcharles MA, Ste-Marie PA, Rampakakis E et al. 2016. Disability in fibromyalgia associates with symptom severity and occupation characteristics. J Rheumatol. [Mar 15 Epub ahead of print.] (In a tertiary facility in Canada) "The prevalence of disability caused by FM was 30.8%. There were no demographic differences among the working, unemployed, or disabled patients. With the exception of measures for anxiety and depression, all measurements for disease severity differed significantly among the groups, with greater severity reported for the disabled group, which used more medications and participated less in physical activity. Disabled patients were more likely previously employed in manual professions or the service industry, whereas employed patients were more commonly working in non-manual jobs that included clerical, managerial, or professional occupations…. The one-third rate of disability for this Canadian cohort of patients with FM is in line with other reports from the western world. Associations of disability compensation were observed for subjective report of symptom severity, increased use of medications, and previous employment in more physically demanding jobs."

Fitzcharles MA, Ste-Marie PA, Shir Y et al. 2014. Management of fibromyalgia in older adults. Drugs Aging. 31(10):711-719. "Although the focus symptom of FM is generalized body pain, patients may also experience sleep and mood disturbance, fatigue, and other somatic symptoms leading to the concept of a polysymptomatic condition. In view of prevalent other comorbidities in older patients, FM may be overlooked and management may be neglected, thereby contributing to poor well-being. Pertinent to the older patient is to ensure that the diagnosis of FM is correct and that other conditions are not misdiagnosed as FM. Wherever possible, treatment strategies should emphasize non-pharmacologic interventions that encompass healthy lifestyle habits, with attention to adequate physical activity in particular. Drug treatments should be tailored to the individual needs of the patient, with knowledge that they may offer only a modest effect, but with caution to ensure that adverse effects do not overshadow therapeutic effects."

Fitzcharles MA, Yunus MB. 2012. The clinical concept of fibromyalgia as a changing paradigm in the past 20 years. Pain Res Treat. 2012:184835. Fibromyalgia (FMS) is a valid clinical condition that affects 2%-4% of the population with a pivot symptom of widespread body pain. The cause and cure of FMS are as yet unknown. The concept of FMS has evolved over the past two decades to incorporate symptoms beyond pain as contributing to the global spectrum of suffering. FMS is now recognized to be grounded in the neurological domain with evidence of dysregulation of pain processing. Appreciation of the neurophysiologic mechanisms operative in FMS has contributed to rational treatment recommendations, although a "gold standard treatment" does not currently exist. Ideal treatments for FMS patients should be individualized with emphasis on active patient participation, good health practices, and multimodal intervention, incorporating nonpharmacologic and pharmacologic treatments. Predictors of outcome, which is favorable in over 50% of patients, are unknown, but those with better outcome do more physical activity and use fewer medications. Free Article

Fitzgerald MP, Kotarinos R. 2003.  Rehabilitation of the short pelvic floor. I: Background and patient evaluation.  Int Urogynecol J Pelvic Floor Dysfunct. 14(4):261-268. (See next entry)

Fitzgerald MP, Kotarinos R. 2003.  Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor.  Int Urogynecol J Pelvic Floor Dysfunct. 14(4):269-275.  These articles provide options for patient care and help for the diagnoses and treatment of many common but often misdiagnosed pelvic and lower abdominal pain cases.  Care providers are reminded that myofascial TrPs can cause dysfunction such as muscle weakness as well as pain, and many cases of bladder and bowel dysfunction, vulvodynia, and similar ailments may be greatly relieved by TrP treatment.

Fiz J, Duran M, Capella D et al. 2011. Cannabis use in patients with fibromyalgia: effect on symptoms relief and health-related quality of life. PLoS One. 6(4):e18440. "The use of cannabis was associated with beneficial effects on some FM symptoms."

Flanagan, D. E. , J. C. Vaile, G. W. Petley, V. M. Moore, I. F. Godsland, R. A. Cockington, J. S. Robinson and D. I. Phillips. 1999. The autonomic control of heart rate and insulin resistance in young adults. J Clin Endocrinol Metab 84(4):1263-7. 

Flax, B. J.  1995.  Myofascial pain syndomes–the great mimicker.  Bol Assoc Med P R 87(10-12):167-170.

Fleckenstein J, Zaps D, Ruger LJ et al. 2010. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey. BMC Musculoskel Disord. 11(1):32. “Myofascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the general population. Current guidelines for the management of myofascial pain are not available. In this study we investigated how physicians on the basis of prescription behavior evaluate the effectiveness of treatment options in their management of myofascial pain…..Effectiveness ratings of the various treatment options between specialties were widely variant. 54.3% of all physicians characterized the available treatment options as insufficient.” “Myofascial pain was estimated a prevalent condition. Despite a variety of commonly prescribed treatments, the moderate effectiveness ratings and the frequent characterizations of the available treatments as insufficient suggest an urgent need for clinical research to establish evidence-based guidelines for the treatment of myofascial pain syndrome.” [We are approaching a stage where the medical community is beginning to recognize that myofascial pain is terribly important across a wide range of medical fields, knowledge of individual TrPs is vital before one can hope to manage complex CMP, it takes a long time to learn TrPs, and the number of care providers trained in myofascial medicine is woefully low.  DJS]

 

Fleury B. 2000.  [Pharyngeal musculature and obstructive sleep apnea syndromes]  Rev Mal Respir. 17 Suppl 3:S15-20. [French]  “The caliber of the pharynx at the soft palate depends on the action of the tensor veli, the palatoglossus, the palatopharyngeus and the uvula muscles.  At the lingual level, the action of the genioglossus and the geniohyoideus predominate.  These different muscle groups contract in coordination before the diaphragm contracts.  Their activity is diminished and disorganized during sleep.  These muscles appear to have a histological composition adapted to short duration intense contractions making them vulnerable to fatigue.  In apneic patients, these muscles are solicited constantly.  Muscular lesions related to overwork have been suggested.”  [Muscle tension can affect sleep apnea.  Myofascial TrPs can affect muscle tension.  Therefore, myofascial TrPs can affect sleep apnea. DJS]

Florencio LL, Ferracini GN, Chaves TC et al. 2016. Active trigger points in the cervical musculature determine altered activation of superficial neck and extensor muscles in women with migraine. Clin J Pain. [Jun 2 Epub ahead of print.] "Previous studies have demonstrated the presence of active TrPs in women with migraine reproducing their headache attacks. No study has investigated if these TrPs can alter muscle function in the cervical spine in migraine. Our objective was to analyze differences in activation of superficial neck flexor and extensor muscles in women with migraine considering the presence of active trigger points (TrP) in splenius capitis (SC), upper trapezius (UT), and sternocleidomastoid (SCM) muscles…." This study found that trigger points in the neck muscles caused the change in muscle activation.

Fogelman Y, Carmeli E, Minerbi A et al. 2017. Specialized pain clinics in primary care: Common diagnoses, referral patterns and clinical outcomes - Novel pain management model. Adv Exp Med Biol. [Oct 5 Epub ahead of print] "An estimated 19% of the adult population in western countries lives with chronic pain. Pain management lies mainly within the primary care and community setting. We evaluated the outcome of a new model of secondary care clinics, conducted by primary care physicians with specialized training in pain medicine. Data on referral patterns, prevalence of pain diagnosis, and medication consumption were recorded at five secondary pain management clinics in the community setting….Myofascial pain syndrome was the most common diagnosis (82%). Treatment included dry needling or trigger point injection (82%), manual myofascial release (23%), and pharmacotherapy (38%). Significant short-term improvement after treatment was reported by 75% of patients, and 72% reported long-term improvement. Four percent were referred to tertiary care pain clinics, 5% were referred to other specialists, and 5% to imaging. Secondary, community-based pain clinics, run by specially-trained primary physicians, demonstrated feasibility. The vast majority of patients referred to the clinics were treated using simple, inexpensive modalities, while sparing referrals to unnecessary consultation visits, imaging tests, and medications."

Fogelman Y, Kent J. 2014. Efficacy of dry needling for treatment of myofascial pain syndrome. J Back Musculoskelet Rehabil. Oct 15. [Epub ahead of print] "Myofascial pain is a major cause of musculoskeletal regional pain. Myofascial pain, which is a high-prevalence but eminently treatable condition, is almost universally underdiagnosed by physicians and undertreated by physical therapy modalities Large numbers of patients can be left suffering in chronic pain for years. Dry needling, also referred to as Intramuscular Stimulation, is a method in the arsenal of pain management which has been known for almost 200 years in Western medicine, yet has been almost completely ignored. With the increase in research in this field over the past two decades, there are many high-quality studies that demonstrate dry needling to be an effective and safe method for the treatment of myofascial pain when diagnosed and treated by adequately-trained physicians or physical therapists. This article provides an overview of recent literature regarding the treatment of myofascial pain syndrome, evidence for the efficacy of dry needling as a central component of its management, and a glimpse at developments in recent imaging methods to aid in the treatment of these problems."

Folci M, Capsoni F. 2016. Arthralgias, fatigue, paresthesias and visceral pain: can joint hypermobility solve the puzzle? A case report. BMC Musculoskel Disord. 17(1):58. "Describing the case of a 20-year-old female with generalized arthro-myalgias, persistent fatigue and troublesome visceral pain, we illustrate how a frequently ignored clinical sign such as joint hypermobility can be the keystone to clarify different simultaneous symptoms. All of the patient's physical complaints had been investigated separately during her previous medical examinations, and several tests repeatedly gave negative results. The patient received different diagnoses that describe only part of her problems, such as irritable bowel syndrome for visceral pain, fibromyalgia for arthralgias or depression for fatigue. These approaches gave rise to pharmacological or physical treatments which did not improve her quality of life in any way and in some instances worsened the situation. Pronounced joint hypermobility which led the patient to flex her joints excessively, causing subluxations in several districts, was the only sign overlooked….Exploring the patient's articular features in her clinical context led us to diagnose joint hypermobility syndrome, a complex and often ignored condition."

Ford, ES, Giles WH, Dietz WH. 2002. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA Jan16;287(3):356-9.  About 47 million US residents have the metabolic syndrome, according to 2000 census data.

Forman MB, Sutej PG, Jackson EK. 2011. Hypertension, tachycardia, and reversible cardiomyopathy temporally associated with milnacipran use. Tex Heart Inst J. 38(6):714-718. "Milnacipran is a dual and equipotent inhibitor of norepinephrine and serotonin uptake. It is frequently prescribed as therapy for fibromyalgia, and the drug has a good safety profile. Herein, we report the case of a 42-year-old woman with undefined connective-tissue disease and fibromyalgia who developed a severe and reversible cardiomyopathy while taking recommended doses of milnacipran. The cardiomyopathy was associated with a hyperadrenergic state manifested by tachycardia, hypertension, and elevated plasma catecholamine levels. The discontinuation of milnacipran and the initiation of anti-failure therapy resulted in complete resolution of the cardiomyopathy in 6 months. To our knowledge, this is the first report of milnacipran as a possible cause of catecholamine-induced cardiomyopathy."

Forrest JB, Schmidt S. 2004.  Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity.  J Urol. 172(6 Pt 2):2561-2562.  “Interstitial cystitis in males appears to be more common than historically reported.  Interstitial cystitis in males and patients with chronic pelvic pain syndrome and chronic nonbacterial prostatitis share many clinical findings.  A higher incidence of interstitial cystitis had been found in American Indian males of Cherokee descent and deserves further investigation.”

Forseth KO, Hafstrom I, Husby G et al. 2010. Comprehensive rehabilitation of patients with rheumatic diseases in a warm climate: a literature review. J Rehabil Med. 42(10):897-902. "In groups with mixed rheumatic diagnoses, low evidence was found for reduction of pain, activity limitation, global disease impact and improved health-related quality of life. No studies on psoriatic arthritis, osteoarthritis, fibromyalgia or osteoporosis were found.....Well-designed studies to validate and improve the low-to-moderate evidence found for the efficacy of comprehensive rehabilitation in a warm climate among patients with inflammatory rheumatic disease are greatly needed."

Forst R, Ingenhorst A. 2005.  [Myofascial pain syndrome]  Internist [Oct 15 Epub ahead of print] [German]  “Untreated, the myofascial pain syndrome leads to a reduced extensibility of the involved muscle with consecutive decrease of the range of motion and development of a muscular imbalance resulting in a disturbance of complex movement and evolution of a chronic pain disease.  An early started and aimed therapy can prevent effectively the chronification.”

Fouad LS, Chen AH, Pettit PD et al. 2015. Transvaginal trigger point injections for pelvic floor myofascial spasm: A retrospective review of pain assessment and development of a treatment algorithm. J Minim Invasive Gynecol. 22(6S):S247-S248. Gynecology, Mayo Clinic, Jacksonville, Florida.

Fox AD, Kunins HV, Starrels JL. 2012. Which skills are associated with residents' sense of preparedness to manage chronic pain? J Opioid Manag. 8(5):328-336. "Few internal medicine residents felt prepared to manage CNMP. Our findings suggest that educational interventions to improve residents' preparedness to manage CNMP should target complex pain syndromes (e.g., fibromyalgia and neuropathic pain), safer opioid prescribing practices, and alternatives to opioid analgesics." [I strongly urge them to add myofascial trigger points and chronic myofascial pain to this list of pain sources. DJS]

Fox C, Walker-Bone K. 2015. Evolving spectrum of HIV-associated rheumatic syndromes. Best Pract Res Clin Rheumatol. 29(2):244-258. "Rheumatological manifestations of HIV were first described in 1989. Since then, there have been case reports, case series and epidemiological studies describing different clinical manifestations of HIV in the musculoskeletal system. This review will encompass musculoskeletal pain, fibromyalgia, systemic lupus erythematosus (SLE) and inflammatory arthritis in HIV. We will aim to report on the prevalence of these conditions and the risk factors, explore the impact of the virus on the clinical presentations and discuss implications for diagnosis and management."

Frampton M, Harvey RJ, Kirchner V. 2003.  Propentofylline for dementia.  Cochrane Database Syst Rev (2):CD002853.  This study is included on this website because this medication is being studied as a spinal glial cell modulator for central sensitization.  It crosses the blood-brain barrier.

Franco C, Bengtsson BA, Johannsson G. 2001.  Visceral obesity and the role of the somatotropic axis in the development of metabolic complications.  Growth Horm IGF Res 11:S97-S102.  “Several studies have described a range of metabolic disturbances associated with abdominal obesity, including glucose intolerance, hyperinsulinaemia, insulin resistance, hypertension and dyslipoproteinaemia, now widely known as the metabolic syndrome.  Several abnormalities in the hypothalamic-pituitary axis have been described associated with visceral obesity, suggesting a central neuroendocrine dysregulation including increased cortisol concentration and impaired gonadotropin and growth hormone (GH) secretion.”

Franco C, Bengtsson BA, Johannsson G. 2001.  Visceral obesity and the role of the somatotropic axis in the development of metabolic complications.  Growth Horm IGF 11:S97-S102.  “Several studies have described a range of metabolic disturbances associated with abdominal obesity, including glucose intolerance, hyperinsulinaemia, insulin resistance, hypertension and dyslipoproteinaemia, now widely known as the metabolic syndrome.  Several abnormalities in the hypothalamic-pituitary axis have been described associated with visceral obesity, suggesting a central neuroendocrine dysregulation including increased cortisol concentration and impaired gonadotropin and growth hormone (GH) secretion.”

Francois A, Laffray S, Pizzoccaro A et al. 2014. T-type calcium channels in chronic pain: mouse models and specific blockers. Pflugers Arch. 466(4):707-717. "Pain is a quite frequent complaint accompanying numerous pathologies. Among these pathological cases, neuropathies are retrieved with identified etiologies (chemotherapies, diabetes, surgeries…) and also more diffuse syndromes such as fibromyalgia. More broadly, pain is one of the first consequences of the majority of inherited diseases. Despite its importance for the quality of life, current pain management is limited to drugs that are either old or with a limited efficacy or that possess a bad benefit/risk ratio. As no new pharmacological concept has led to new analgesics in the last decades, the discovery of medications is needed, and to this aim the identification of new druggable targets in pain transmission is a first step. Therefore, studies of ion channels in pain pathways are extremely active. This is particularly true with ion channels in peripheral sensory neurons in dorsal root ganglia (DRG) known now to express unique sets of these channels. Moreover, both spinal and supraspinal levels are clearly important in pain modulation. Among these ion channels, we and others revealed the important role of low voltage-gated calcium channels in cellular excitability in different steps of the pain pathways. These channels, by being activated nearby resting membrane potential have biophysical characteristics suited to facilitate action potential generation and rhythmicity. In this review, we will review the current knowledge on the role of these channels in the perception and modulation of pain."

Francois, P. P., K. T. Preissner, M. Herrmann, R. P. Haugland, P. Vaudaux, D. P. Lew and K. H. Krause.  1999.

Frank, E. M. 1999. Myofascial trigger point diagnostic criteria in the dog. J Musculoskel Pain 7(1-2):231-237.

Franssen JLM, Beersma B, Bron C. 2007.  Shoulder pain during swallowing: the use of surface electromyography as a valuable diagnostic and therapeutic tool in myofascial pain syndrome.  J Musculoskel Pain 15 (Supp 13):22 item 33.  [Myopain 2007 Poster]  “MPS should be considered as a possible cause of musculoskeletal complaints in neck or shoulder disorders.  Surface electromyography can be of great benefit in the process of differential diagnosis and may be illuminate non-physiological motor behavior, which is one of the perpetuating factors in MPS.  The knowledge of referred pain patterns may be helpful in identifying the muscle to be treated.”  [This is a very interesting study, as the MTPs were initiated due to use of endotracheal tube during surgery, and the referral pain pattern occurred during swallowing.  Having experienced TPM cascade from endotracheal intubation myself, I know how difficult this can be and how unaware most anesthesiologists and other medical team members are that this can occur.  DJS]

Fredheim OM, Borchgrevink PC, Klepstad P et al. 2006.  Long term methadone for chronic pain: a pilot study of pharmacokinetic aspects.  [Nov 16 Epub ahead of print] Eur J Pain  “...a 3-day opioid switch from morphine to methadone followed by a one week titration seems pharmacologically sound.”  These patients had chronic non-malignant pain.  Methadone serum concentrations did not change significantly from dose titration through 9 months therapy.

Fredheim OM, Kaasa S, Dale O et al. 2006.  Opioid switching from oral slow release morphine to oral methadone may improve pain control in chronic non-malignant pain: a nine-month follow-up study.  Palliat Med. 20(1):35-41.

Fredheim OM, Kaasa S, Fayers P et al. 2007.  Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients.  Acta Anaesthesiol Scand. [Nov 13 Epub ahead of print].  “CNMP patients admitted to multidisciplinary pain centres report significantly reduced HRQoL, in addition to severe pain.  They consider their HRQoL to be as poor as HRQoL reported from dying cancer patients and substantially poorer than national norms.”  [This leaves one to wonder about the ethics of having a substantial group of patients, those with chronic non-cancer pain, with a quality of life lower than terminal cancer patients.  How can any system allow this situation, and what will it take to improve it?  DJS]

Fredheim OM, Mahic M, Skurtveit S et al. 2014. Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian prescription database and the Nord-Trondelag health study. Pain. [Mar 15 Epub ahead of print.] "The study showed that most people having chronic nonmalignant pain are not using opioids, even if the pain is strong or very strong. However, the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment." [This should not be interpreted to mean that opioids do not help chronic pain. In this increasingly wary culture, many chronic pain patients are denied access to adequate opioid pain medications. Opioids should not be used as the only treatment, but can be a logical part of the management of some chronic pain treatment plans. Efforts also must be made to treat the cause of the pain, such as myofascial trigger points, and the perpetuating factors of that cause. Doctors and other care providers who are involved in any pain management must be trained in the diagnosis and treatment of the most common cause of musculoskeletal pain; myofascial trigger points. DJS]

Freeman MD, Nystrom A, Centeno C. 2009.  Chronic whiplash and central sensitization; an evaluation of the role of a myofascial trigger point in pain modulation.  J Brachial Plex Peripher Nerve Inj. 4:2.  “Conclusion: the present data suggest that myofascial trigger points serve to perpetuate lowered pain thresholds in uninjured tissues.”   [This study indicates that TrPs perpetuate central sensitization (FM).  The effects of TrP treatment on lowered pain thresholds were temporary, perhaps because the perpetuating factors and follow-up treatment did not occur.  The authors contemplated surgical removal or ablation of TrPs, which is not logical considering the physiology of TrP formation, and it is hoped that the authors will study the Travell and Simons texts and current research before continuing to treat myofascial pain.  Trauma, including surgery, can be an initiator and perpetuator of TrPs and could promote further chronic pain. DJS]

Fregni F, Gimenes R, Valle AC et al. 2006.  A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia.  Arthritis Rheum. 54(12):3988-3998.  “Our findings provide initial evidence of a beneficial effect of tDCS in fibromyalgia, thus encouraging further trials.”

Fricton J. 2016. Myofascial pain: Mechanisms to management. Oral Maxillofac Surg Clin North Am. 28(3):289-311. "More than 100 million adults in the United States have chronic pain conditions, costing more than $500 billion annually in medical care and lost productivity. They are the most common reason for seeking health care, for disability and addiction, and the highest driver of health care costs. Myofascial pain is the most common condition causing chronic pain and can be diagnosed through identifying clinical characteristics and muscle palpation. Management is focused on integrating patient training in changing lifestyle risk factors with evidence-based treatment. Understanding the cause, diagnosis, and management of myopain conditions will help prevent the impact of chronic pain."

Fricton JR, Kroening R, Haley D et al. 1985.  Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 60(6):615-623.  “Misdiagnosis or inadequate management of this disorder after onset may lead to development of a complex chronic pain syndrome.”  [This is a study of 164 patients, as true today as it was when it was written.  Far too many dentists have no knowledge of myofascial pain, and this lack of knowledge on their part results in far too many chronic pain patients.  DJS]

Fricton JR, Steenks MH. 1996.  [Diagnosis and treatment of myofascial pain] Ned Tijdschr Tandheelkd. 103(7):249-253.  [Dutch]  “MFP is frequently overlooked as a diagnosis because it is often accompanied by signs and symptoms in addition to pain….”   “The difficulty in managing MFP lies in the critical need to match the level of complexity of the management program with the complexity of the patient.  Failure to address the entire problem may lead to failure to resolve the pain and perpetuation of a chronic pain syndrome.”

Friedman, D. P. 1990.  Perspectives on the medical use of drugs of abuse.  J Pain Symptom Manage 5(1 Suppl):S2-S5.

Friedman M, Gurpinar B, Lin HC et al. 2007.  Impact of treatment of gastroesophageal reflux on obstructive sleep apnea-hypopnea syndrome.  Ann Otol Rhinol Laryngol. 116(11):805-811.  “Treatment of GERD had a significant impact on the reduction of the apnea-hypopnea index, snoring, and daytime sleepiness.  Elimination of GERD should be part of a comprehensive treatment plan for patients with OSAHS.” 

Frokjaer JB, Andersen SD, Gale J et al. 2005.  An experimental study of viscero-visceral hyperalgesia using an ultrasound-based multimodal sensory testing approach.  Pain [Nov 15 Epub ahead of print]. “Central mechanisms can explain the remote hyperalgesia to mechanical visceral stimulation and the increase in referred pain areas.”

Fruchwald-Schultes B, Kern W, Born J, et al.. 2001.  Hyperinsulinemia causes activation of the hypothalamus-pituitary-adrenal axis in humans.  Int J Obes Relat Metab Disord 25 Suppl 1:S38-40. Hyperinsulinemia acutely increases HPA secretory activity in healthy men.

Fruth SJ. 2006.  Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Phys Ther. 86(2):254-268.  “This case suggests that CV/CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient.”  This case is interesting in that myofascial dysfunction occurred after a 35-year old man had been on the  bleachers at a hockey game for 3 hours. Two days later he had pain in the right scapular area and spine that increased during the next 6 weeks. He had considerable pain, lost some function and range of motion and had difficulty sleeping due to movement-triggered pain. He was subjected to weeks of physical therapy including spine mobilization, and given many expensive radiological tests. After months of this, trigger points were found in multiple area muscles. After 4 weeks of specific treatment the patient had full return to function. [How much pain is needless, and how much time and other resources are wasted, because we do not have care providers who are adequately trained in the diagnosis and treatment of myofascial TrPs? DJS]

Fuentes-Marquez P, Valenza MC, Cabrera-Martos I et al. 2017. Trigger points, pressure pain hyperalgesia, and mechanosensitivity of neural tissue in women with chronic pelvic pain. Pain Med. [Aug 25 Epub ahead of print] "Forty women with chronic pelvic pain between age 18 and 60 years and 40 matched healthy controls were included in the study….TrPs were bilaterally explored in gluteus maximus, gluteus medius, gluteus minimus, quadratus lumborum, and adductor magnus muscles. The referred pain reproduced lumbopelvic symptoms. Pressure pain thresholds (PPTs) were also bilaterally assessed over the Pfannenstiel incision point on the abdominal, C5-C6 zygapophyseal joint, second metacarpal, and tibialis anterior muscle. Mechanosensitivity of neural tissue was assessed with the neurodynamics tests of slump and the straight-leg raising….Patients with chronic pelvic pain presented a high percentage of TrPs that reproduce their symptoms. Patients also showed a widespread pressure pain hyperalgesia and more mechanosensitive neural tissue due to a decrease on the range of motion related to neurodynamics."

Fulle S., Mecocci P., Fano G., Vecchiet I., Vecchini A., Racciotti D., Cherubini A., Pizzigallo E., Vecchiet, Senin U., Beal M.F. 2000.  Specific oxidative alterations in vastus lateralis muscle of patients with the diagnosis of chronic fatigue syndrome. Free Radic Biol Med 29(12):1252-9. Patients with chronic fatigue syndrome have differences in muscle membranes, fluidity and fatty acid composition compared to patients with fibromyalgia and healthy patients.

Furlan AD, Sandoval JA, Mailis-Gagnon A et al. 2006.  Opioids for chronic non-cancer pain: a meta-analysis of effectiveness and side effects.  CMAJ 174(11):1589-1594.  “Weak and strong opioids outperformed placebo for pain and function in all types of CNCP.  Other drugs produced better functional outcomes than opioids, whereas for pain relief they were outperformed only by strong opioids.  Despite the relative shortness of the trials, more than one-third of the participants abandoned treatment.”   This study included patients with fibromyalgia.  “Among the side effects for opioids, only constipation and nausea were clinically and statistically significant.”

Furnes B, Dysvik E. 2010. Dealing with grief related to loss by death and chronic pain: An integrated theoretical frame work. Part 1. Patient Prefer Adherence. 4:135-140. "Two main themes were formulated, 'relearning the world' and 'adaptation'. Between these themes a continuous movement emerged involving experience such as: 'despair and hope', 'lack of understanding and insight', 'meaning disruption and increased meaning', and 'bodily discomfort and reintegrated body'." "Grief as a distinctive experience means that health care must be aimed at each individual experience and situation." [This article explains why care providers and supporters of patients dealing with chronic pain situations need to understand the enormity of life disruption that a chronic pain state can bring.]

Ga H, Choi JH, Park CH et al. 2007.  Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients – a randomized trial.  Acupunct Med. 25(4):130-136.  “There was no significant difference between acupuncture needling and 0.5% lidocaine injection of trigger points for treating myofascial pain syndrome in elderly patients.”

Ga H, Koh HJ, Choi JH et al. 2007.  Intramuscular and nerve root stimulation vs. lidocaine injection to trigger points in myofascial pain syndrome.  J Rehabil Med. 39(5):374-378.  “In managing myofascial pain syndrome, after one month intramuscular stimulation resulted in more significant improvements in pain intensity, cervical range of motion and depression scales than did 0.5% lidocaine injection of trigger points.  Intramuscular stimulation is therefore recommended for myofascial pain syndrome.”

Gagnon I, Swaine B, Friedman D et al. 2004.  Children show decreased dynamic balance after mild traumatic brain injury. Arch Phys Med Rehabil 85(3):444-452. Even mild traumatic brain injury can cause postural balance dysfunction in children 10 weeks after the injury.

Galic MA, Persinger MA. 2007.  Lagged association between geomagnetic activity and diminished nocturnal pain thresholds in mice.  Bioelectromagnetics [Jul 26 Epub ahead of print].  “If the geomagnetic activity was greater 3 days before a given hotplate trial, subjects tended to exhibit shorter response latencies, suggesting lower pain thresholds or less analgesia.  These results are supported by related experimental findings and suggest that natural variations in geomagnetic intensity may influence nociceptive behaviors in mice.”  [This study, although done in mice, may have implications for electromagnetic sensitivity observed in some FM patients.  DJS]

Galinier, M., J. Fourcade, N. Ley, S. Boveda, S. Solera, M. L. Solera, P. Massabuau, S. Elhabaj, J. M. Fauvel, P. Valdiguie and J. P. Bounhoure. 1999. [No title available] Arch Mal Coeur Vaiss 92(8):1105-9. [French] 

Galland L. 2014. The Gut Microbiome and the Brain. J Med Food. 17(12):1261-1272. "The human gut microbiome impacts human brain health in numerous ways: (1) Structural bacterial components such as lipopolysaccharides provide low-grade tonic stimulation of the innate immune system. Excessive stimulation due to bacterial dysbiosis, small intestinal bacterial overgrowth, or increased intestinal permeability may produce systemic and/or central nervous system inflammation. (2) Bacterial proteins may cross-react with human antigens to stimulate dysfunctional responses of the adaptive immune system. (3) Bacterial enzymes may produce neurotoxic metabolites such as D-lactic acid and ammonia. Even beneficial metabolites such as short-chain fatty acids may exert neurotoxicity. (4) Gut microbes can produce hormones and neurotransmitters that are identical to those produced by humans. Bacterial receptors for these hormones influence microbial growth and virulence. (5) Gut bacteria directly stimulate afferent neurons of the enteric nervous system to send signals to the brain via the vagus nerve. Through these varied mechanisms, gut microbes shape the architecture of sleep and stress reactivity of the hypothalamic-pituitary-adrenal axis. They influence memory, mood, and cognition and are clinically and therapeutically relevant to a range of disorders, including alcoholism, chronic fatigue syndrome, fibromyalgia, and restless legs syndrome. Their role in multiple sclerosis and the neurologic manifestations of celiac disease is being studied. Nutritional tools for altering the gut microbiome therapeutically include changes in diet, probiotics, and prebiotics."

Galland L. 2006.  Patient-centered care: antecedents, triggers and mediators.  Altern Ther Health Med. 12(4):62-70.  “Functional medicine is essentially patient centered, rather than disease centered.  A structure is presented for uniting a patient-centered approach to diagnosis and treatment with the fruits of modern clinical science (which evolved primarily to serve the prevailing model of disease-centered care).  The core scientific concepts of disease pathogenesis are antecedents, triggers, and mediators.  Antecedents are factors, genetic or acquired, that predispose to illness; triggers are factors that provoke the symptoms and signs of illness; and mediators are factors, biochemical or psychosocial, that contribute to pathological changes and dysfunctional responses.  Understanding the antecedents, triggers, and mediators that underlie illness or dysfunction in each patient permits therapy to be targeted to the needs of the individual.  The conventional diagnosis assigned to the patient may be of value in identifying plausible antecedents, triggers or mediators for each patient, but is not adequate by itself for the designing of patient-centered care.  Applying the model of person-centered diagnosis to patients facilitates the recognition of disturbances that are common in people with chronic illness.  Diet, nutrition, and exposure to environmental toxins play central roles in functional medicine because they may predispose to illness, provoke symptoms, and modulate the activity of biochemical mediators through a complex and diverse set of mechanisms.  Explaining those mechanisms is a key objective of the Textbook of Functional Medicine (from which this article is excerpted).  A patient's beliefs about health and illness are critically important for self-care and may influence both behavioral and physiological responses to illness.  Perceived self-efficacy is an important mediator of health and healing.  Enhancement of patients' self-efficacy through information, education, and the development of a collaborative relationship between patient and healer is a cardinal goal in all clinical encounters.”  [ I strongly recommend this textbook for any doctor who has patients with chronic illness.  It will help them get to the cause of some of the metabolic dysfunctions. DJS]

Gallant MP, Tartaglia M, Hardman S et al. 2017. Using tai chi to reduce fall risk factors among older adults: An evaluation of a community-based implementation. J Appl Gerontol. [Apr 1 Epub ahead of print] This test from New York was done with the New York State Department of Health: "This study aimed to evaluate a community-based implementation of an evidence-based fall prevention program, in which 131 individuals participated in Tai Chi: Moving for Better Balance….The mostly female participants were 73 years old, on average…. These results demonstrate that a 12-week evidence-based Tai Chi program can be feasibly implemented by novice instructors, is well-received by older adults, and can effectively reduce fall risk when implemented in community settings."

Galski, T., J. B. Williams and H. T. Ehle.  2000.  Effects of opioids on driving ability.  J Pain Symptom Manage 19(3):200-8.

Galvez-Sanchez CM, Muñoz Ladron de Guevara C, Montoro CI et al. 2018. Cognitive deficits in fibromyalgia syndrome are associated with pain responses to low intensity pressure stimulation. PLoS One. 13(8):e0201488. "It may be concluded that pain experience during somatosensory stimulation of low intensity is more closely related to attention, memory and executive functions in FMS than the traditional measures of pain threshold and pain tolerance. Considering that pain responses to low intensity stimulation reflect the hyperalgesia and allodynia phenomena characterizing FMS, it may be hypothesized that central nervous pain sensitization is involved in cognitive impairments in the disorder." Free Article

Gamal-Eltrabily M, Manzano-García A. 2017. Role of central oxytocin and dopamine systems in nociception and their possible interactions: suggested hypotheses. Rev Neurosci. [Dec 9 Epub ahead of print] "Central oxytocin and dopamine have an important role in the process of nociception at the spinal level as well as supraspinal structures, e.g. anterior cingulate cortex, insular cortex, amygdala, nucleus accumbens, and hypothalamus. Many studies have pointed out the importance of both systems in the pain descending modulatory system and in pain-related symptoms in some chronic disorders, e.g. Parkinson disease and fibromyalgia. The interaction between oxytocin and dopamine systems has been addressed in some motivational behaviors, e.g. maternal and sexual behaviors, pair bonding, and salience. In this aspect, we propose that an oxytocin-dopamine interaction could be present in nociception, and we also explain the possible hypotheses of such an interaction between these systems."

Gamsa, A.  1990. Is emotional disturbance a precipitator or a consequence of chronic pain? Pain 42(2): 183-195.

Gangi, S. and O. Johansson. 2000. A theoretical model based on mast cells and histamine to explain the recent proclaimed sensitivity to electric and/or magnetic fields in humans. Med Hypos 54(4):663-671. Electromagnetic energy can activate mast cells, a type of connective tissue cell, causing the release of a number of informational substances including hyaluronic acid, vasoactive intestinal polypeptide (VIP, a substance which has been implicated in keeping our HPA-axis in the "fight or flight" stress mode), histamine (which can add to swelling, itching, pain, allergic manifestations and hypersensitivity,) and cause other cells to release somatostatin (which can enhance sensations of inflammation and light sensitivity).

Gao YJ, Zhang L, Ji RR. 2010. Spinal injection of TNF-alpha-activated astrocytes produces persistent pain symptom mechanical allodynia by releasing monocyte chemoattractant protein-1. Glia. [Aug 24 Epub ahead of print]. "Accumulating evidence suggests that spinal astrocytes play an important role in the genesis of persistent pain, by increasing the activity of spinal cord nociceptive neurons, i.e., central sensitization.....We investigated whether and how spinal injection of activated astrocytes could produce mechanical allodynia, a cardinal feature of chronic pain, in....mice.....our results suggest that activated astrocytes are sufficient to produce persistent pain symptom in our mice...." [We can look forward to the development of astrocyte modulators to minimize central sensitization. DJS]

Garbuzenko E, Nagler A, Pickholtz D et al. 2002.  Human mast cells stimulate fibroblast proliferation, collagen synthesis and lattice contraction: a direct role for mast cells in skin fibrosis.  Clin Exp Allergy. 32(2):237-246.  This study indicates that co-existing allergies and the presence of more numerous mast cells may have a significant affect on scarring, formation of adhesions and fibrosis.  One of the two main mast cell mediators involved is histamine, one of the biochemicals produced during MTrP local twitch response.  Allergies may thus be interactive with other conditions in yet one more way.

Garbuzenko E., Nagler A, Pickholtz D et al. 2002. Human mast cells stimulate fibroblast proliferation, collagen synthesis and lattice contraction: a direct role for mast cells in skin fibrosis.  “...mast cells have a direct and potentiating role in skin remodeling and fibrosis.”  [Excess histamine in the system, from allergy, fibromyalgia imbalance, myofascial TrP twitch response, and/or other reasons may directly affect the formation of adhesion and scar tissue.  DJS]

Garcia-Martin E, Garcia-Campayo J, Puebla-Guedea M, et al. 2016. Fibromyalgia is correlated with retinal nerve fiber layer thinning. PLoS One. 11(9):e0161574. "Fibromyalgia causes subclinical axonal damage in the RNFL (retinal nerve fiber layer) that can be detected using innocuous and non-invasive OCT (optical coherence tomography), even in the early disease stages. The impact on the RNFL in the temporal sectors is greater in patients with biologic fibromyalgia, suggesting the presence of neurodegenerative processes in this subgroup of patients with fibromyalgia". Free Article

Gardner, J. R. and G. Sandhu.  1997.  The stigma and enigma of chronic non-malignant back pain (CNMBP) treated with long-term opioids (LTO).  Contemp Nurse 6(2):61-66. 

Garrison RL, Breeding PC. 2003.  A metabolic basis for fibromyalgia and its related disorders: the possible role of resistance to thyroid hormone.  Med Hypotheses 61(2):182-189.  Thyroid resistance may be a key perpetuating factor of FMS.

Garrido M, Castaño MY, Biehl-Printes C et al. 2017. Effects of a respiratory functional training program on pain and sleep quality in patients with fibromyalgia: A pilot study. Complement Ther Clin Pract. 28:116-121. "Participants underwent a 12-week intervention: 4 weeks as control and 8 weeks of breathing exercises…. Increases in the pain tolerance threshold were detected in the occiput point after one month of intervention as well as in the low cervical and second rib points after one and two months. Actigraphy revealed a decrease in sleep latency, whereas sleep questionnaire showed improvements in sleep quality, sleep duration and sleep efficiency. No changes in cortisol and antioxidant levels were detected."

Garrison AM, Parrott JM, Tunon A et al. 2018. Kynurenine pathway metabolic balance influences microglia activity: Targeting kynurenine monooxygenase to dampen neuroinflammation. Psychoneuroendocrinology. 94:1-10. Chronic stress or inflammation increases tryptophan metabolism along the kynurenine pathway (KP), and the generation of neuroactive kynurenine metabolites contributes to subsequent depressive-like behaviors.... These data are the first to...suggest that KP metabolic balance may play a direct role in regulating microglia activity. [A subset of fibromyalgia patients utilize the kynurenine metabolic pathway to hijack 5-HTP, creating quinolinic acid (a nerve toxin) instead of serotonin). This research may be relevant. Research indicates that spinal cord microglial cells are involved in the central sensitization process, and hence may be involved in the initiation of FM. DJS]

Garvey TA, Marks MR, Wiesel SW. 1989. A prospective, randomized, double-blind evaluation of trigger point injection therapy for low back pain.  Spine 14(9):962-964.  “Trigger point therapy seems to be a useful adjunct in treatment of low back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger point seems to give symptomatic relief equal to that of treatment with various types of injected medication.”  [Chronic low back pain is often due to TrPs.   This has long been known but has not filtered down to the clinician level. DJS]

Gaskell H, Moore RA, Derry S et al. 2016. Oxycodone for pain in fibromyalgia in adults. Cochrane Database Syst Rev. [Sep 1 Epub ahead of print.] "This review replaces part of an earlier review that evaluated oxycodone for both neuropathic pain and fibromyalgia, which has now been split into separate reviews for the two conditions. This review will consider pain in fibromyalgia only…. Most reviews have examined all opioids together. This review sought evidence specifically for oxycodone, at any dose, and by any route of administration…. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE for randomized controlled trials from inception to 25 July 2016. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries…. We planned to include randomised, double-blind trials of eight weeks' duration or longer, comparing oxycodone (alone or in fixed-dose combination with naloxone) with placebo or another active treatment…. No study satisfied the inclusion criteria…. There is no randomized trial evidence to support or refute the suggestion that oxycodone, alone or in combination with naloxone, reduces pain in fibromyalgia."

Gasperi M, Krieger JN, Forsberg C et al. 2017. Chronic prostatitis and comorbid non-urological overlapping pain conditions: A co-twin control study. J Psychosom Res. 102:29-33. "Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by pain and voiding symptoms in the absence of an obvious infection or other cause. CP/CPPS frequently occurs with non-urological chronic overlapping pain conditions (COPCs) of unknown etiology. We conducted a co-twin control study in men discordant for chronic prostatitis (CP), an overarching diagnosis of which approximately 90% is CP/CPPS. The primary aim was to investigate the contribution of familial factors, including shared genetic and common environmental factors, to the comorbidity of CP and COPCs….. There were significant associations between CP and all 6 examined COPCs. After adjusting for shared familial influences in within twin pair analyses, the associations for all COPCs diminished but remained significant. Familial confounding was strongest for the association of CP with fibromyalgia and temporomandibular disorder and smallest for irritable bowel syndrome….CP and COPCs are highly comorbid. These associations can be partially explained by familial factors. The mechanisms underlying these relationships are likely diverse and multifactorial. Future longitudinal research can help to further elucidate specific genetic and environmental mechanisms and determine potentially causal relationships between CP and its comorbidities." [It would have been useful if these patients had been screened for co-existing myofascial TrPs. DJS]

Gaubeca-Gilarranz A, Fernandez-de-Las-Penas C, Medina-Torres JR et al. 2018. Effectiveness of dry needling of rectus abdominis trigger points for the treatment of primary dysmenorrhoea: a randomised parallel-group trial. Acupunct Med. [May 2 Epub ahead of print] "This trial suggests that a single session of TrP-DN of the rectus abdominis combined with stretching was more effective than placebo needling and stretching alone at reducing pain and the amount of medication used in primary dysmenorrhoea."

Ge HY. 2010. Prevalence of myofascial trigger points in fibromyalgia: the overlap of two common problems. Curr Pain Headache Rep. 14(5):339-345. Now that we have objective evidence of the reality of myofascial trigger points, it is becoming more apparent that they contribute to many chronic regional and widespread pain conditions. "Active MTrPs as tonic peripheral nociceptive input contribute tremendously to the initiation and maintenance of central sensitization, to the impairment of descending inhibition, to the increased excitability of motor units, and to the induction of sympathetic hyperactivity observed in FM. The considerable overlap of MTrPs and FM in pain characteristics and pathophysiology suggests that FM pain is largely due to MTrPs."

Ge HY, Arendt-Nielsen L. 2011. Latent myofascial trigger points. Curr Pain Headache Rep May 11 [Epub ahead of print] The treatment of latent TrPs may improve function, decrease sensitivity to pain, prevent the activation of those TrPs, and, if caught in time, may prevent the development of myofascial pain syndrome.

Ge HY, Fernandez-de-Las-Penas C, Madeleine P et al.  2008.  Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle.  Eur J Pain. [Jan 17 Epub ahead of print].  “There exists bilateral mechanical hyperalgesia in patients with unilateral shoulder pain.  Further, the association of multiple active MTPs with unilateral shoulder pain and the heterogeneity of mechanical pain sensitivity distribution suggest a crucial role of peripheral sensitization in chronic myofascial pain conditions.”

Ge HY, Fernandez-de-Las-Penas C, Yue SW. 2011. Myofascial trigger points: spontaneous electrical activity and its consequences for pain induction and propagation. Chin Med. 6(1):13. "Referred pain is dependent on the sensitivity of myofascial trigger points. Active myofascial trigger points may play an important role in the transition from localized pain to generalized pain conditions via the enhanced central sensitization, decreased descending inhibition and dysfunctional motor control strategy."

Ge HY, Monterde S, Graven-Nielsen T et al. 2014. Latent myofascial trigger points are associated with an increased intramuscular electromyographic activity during synergistic muscle activation. J Pain. 15(2):181-7. "The aim of this study was to evaluate intramuscular muscle activity from a latent myofascial trigger point (MTP) in a synergistic muscle during isometric muscle contraction. Intramuscular activity was recorded with an intramuscular electromyographic (EMG) needle inserted into a latent MTP or a non-MTP in upper trapezius at rest and during isometric shoulder abduction at 90° performed at 25% of maximum voluntary contraction in 15 healthy subjects. Surface EMGs were recorded from the middle deltoid muscle, upper-, middle-, and lower- parts of the trapezius muscle. Maximal pain intensity and referred pain induced by EMG needle insertion and maximal pain intensity during contraction were recorded on a visual analogue scale (VAS). The results showed that higher VAS scores were observed following needle insertion and during muscle contraction for latent MTPs than non-MTPs…. The intramuscular EMG activity in the upper trapezius muscle was significantly higher at rest and during shoulder abduction at latent MTPs compared with non-MTPs…. This study provides evidence that latent MTPs are associated with increased intramuscular, but not surface, EMG amplitude of synergist activation. The increased amplitude of synergistic muscle activation may result in incoherent muscle activation pattern of synergists inducing spatial development of new MTPs and the progress to active MTPs." [This study shows one way in which TrPs can develop satellite TrPs, and myofascial trigger point pain and dysfunction can spread to muscles recruited by TrP-weakened muscles to help them. The newly recruited muscles, now also overworked doing tasks they were not designed to do, then need other muscles to help them perform their tasks. This can lead to the false impression of the presence of a progressive illness. DJS]

Ge HY, Nie H, Madeleine P et al. 2009.  Contribution of the local and referred pain from active myofascial trigger points in fibromyalgia syndrome.  Pain. [Oct 8 Epub ahead of print].  “The generalized hypersensitivity associated with fibromyalgia syndrome (FMS) may in part be driven by peripheral nociceptive sources.”  “Active MTrPs bilaterally in the upper trapezius muscle contribute to the neck and shoulder pain in FMS.  Active MTrPs may serve as one of the sources of noxious input leading to the sensitization of spinal and supraspinal pain pathways in FMS.”  [We are getting more confirmation that myofascial TrPs can be in some if not many instances at least one way that the central sensitization we know of as fibromyalgia is maintained.  To treat fibromyalgia adequately, co-existing myofascial TrPs MUST be treated.  Any doctor who treats fibromyalgia patients MUST know how to diagnose and treat patients with myofascial TrPs or they cannot justifiably take money to treat patients for these conditions.  DJS]

Ge HY, Wang Y, Danneskiold-Samsoe B et al. 2009.  The predetermined sites of examination for tender points in fibromyalgia syndrome are frequently associated with myofascial trigger points.  J Pain. [Nov 13 Epub ahead of print]  “The current study provides first evidence that pain from active MTrPs at TP sites mimics fibromyalgia pain.  MTrPs may relate to generalized increased sensitivity in FMS due to central sensitization.”  “…This article underlies the importance of active MTrPs in FMS patients.  Most of the TP sites in FMS are MTrPs.  Active MTrPs may serve as a peripheral generator of fibromyalgia pain and inactivation of active MTrPs may thus be an alternative for the treatment of FMS.”  [It is very good to have such fine research confirm that TrPs themselves can be the cause or maintainer of much FM pain, and that one cannot adequately treat FM without being able to diagnose and treat co-existing TrPs. DJS]

Ge HY, Wang Y, Fernandez-de-Las-Penas C et al. 2011. Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients. Arthritis Res Ther. 13(2):R48. "The overall spontaneous FM pain pattern can be reproduced by mechanical stimulation of active MTPs located in different muscles, suggesting that fibromyalgia pain is largely composed of pain arising from muscle pain and spasm. Targeting active MTPs and related perpetuating factors may be an important strategy in FM pain control." [More research is showing that one cannot treat FM without treating the pain generators, including myofascial TrPs. DJS]

Gear,  R. W., C. Miaskowski, N. C. Gordon,  S. M. Paul, P. H. Heller and J. D. Levine 1996.  Kappa-opioids produce significantly greater analgesia in women than in men.  Nat Med 2(11):1248-1250.

Gedalia A, Garcia CO, Molina JF et al. 2000.  Fibromyalgia syndrome: experience in a pediatric rheumatology clinic.  Clin Exp Rheumatol 18(3):415-419.

Geenen R, Jacobs JW. 2001.  Fibromyalgia: diagnosis, pathogenesis and treatment.  Curr Opin Anaesthesiol. 14(5):533-539.  “Fibromyalgia is a multifaceted problem.”  “…the objective in future evaluations should be to try to find the combined pharmacological or non-pharmacological treatment of choice for specific subgroups of patients.”

Geisser ME, Glass JM, Rajcevska LD et al. 2008. A psychophysical study of auditory and pressure sensitivity in patients with fibromyalgia and healthy controls. J Pain 9(5):417-422. "Muscle tenderness is the hallmark of FM, but the findings of this study and others suggest that persons with FM display sensitivity to a number of sensory stimuli. These findings suggest that FM is associated with a global central nervous system augmentation of sensory information. These findings may also help to explain why persons with FM display a number of comorbid physical symptoms other than pain." [As suspected and noted in my books and on the website handouts, the sensory amplification of FM does not stop with pain. This means that the autonomic and proprioceptive symptoms of co-existing MTPS, such as dizziness, for example, may be greatly amplified. Care providers and patients must be made aware of this to avoid expensive and possibly unnecessary testing and procedures. DJS]

Gelfand , M. M . 2000.  Sexuality among older women. J Womens Health Gend Based Med Suppl 1:S15-20.

Geller EJ, Babb E, Nackley AG et al. 2016. Incidence and risk factors for pelvic pain following mesh implant surgery for the treatment of pelvic floor disorders. J Minim Invasive Gynecol. [Oct 20 Epub ahead of print.] This is a retrospective study of women with no baseline pelvic pain who underwent surgery with mesh implant for the treatment of prolapse and/or incontinence at least one year prior to study period…. One in six women reported de novo (new) pelvic pain after pelvic mesh implant surgery, with decreased sexual function. Risk factors included younger age, fibromyalgia, early postoperative pain, poorer physical health, and somatization." [TrPs were not included in these assessments, as this was a retrospective study and patients were not available. According to the lead author, they will be included in future studies. One is underway and will be published next year. DJS]

Gemignani F, Vitetta F, Brindani F et al. 2012. Painful polyneuropathy associated with restless legs syndrome. Clinical features and sensory profile. Sleep Med. [Oct 3 Epub ahead of print]. "RLS is frequently associated with painful polyneuropathy, in keeping with the hypothesis that its occurrence is favored by small fiber involvement. It represents a heterogeneous entity, differentiated in chronic and remitting-intermittent subtypes, possibly conditioned by indolent or aggressive neuropathy course and phenomena of central sensitization."

Gemmell C, Leathem JM. 2006.  A study investigating the effects of Tai Chi Chuan: individuals with traumatic brain injury compared to controls.  “Tai Chi provides short-term benefits after TBI, with rigorous outcome measurement needed to examine long-term benefits.”

Genazzani, A. R., A. Spinetti, R. Gallo and F. Bernardi.  1999.  Menopause and the central nervous system: intervention options.  Maturitas 31(2):103-10.

Genc A, Tur BS, Aytur YK et al. 2015. Does aerobic exercise affect the hypothalamic-pituitary-adrenal hormonal response in patients with fibromyalgia syndrome? J Phys Ther Sci. 27(7):2225-31.This study from Turkey supports the concept that: "there is a dysregulation of the HPA axis in patients with FM, and that a six-week exercise program can influence symptoms and affect the HPA axis hormones." Free PMC Article

Gendreau M, Hufford MR, Stone AA. 2003.  Measuring clinical pain in chronic widespread pain: selected methodological issues.  Best Pract Res Clin Rheumatol 17(4):575-592.  “Patients pain reports can be systematically biased by a number of methodological factors.”

Geneen LJ, Moore RA, Clarke C et al. 2017. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 4:CD011279. "The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews. There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life. The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period."

Genter, P. M. and E. Ipp.  1994.  Accuracy of plasma glucose measurements in the hypoglycemic range. Diabetes Care 17(6):595-598.  Any interpretation or comparison of critical clinical and research measurements of glucose in different settings take into account methodological differences, particularly in the hypoglycemic range. 

Gentili, A. and J. D. Edinger.  1999.  Sleep disorders in older people.  Aging (Milano) 11(3):137-41.

Geranton SM, Tochiki KK. 2015. Regulation of gene expression and pain states by epigenetic mechanisms. Prog Mol Biol Transl Sci. 131:147-183. "The induction of inflammatory or neuropathic pain states is known to involve molecular activity in the spinal superficial dorsal horn and dorsal root ganglia, including intracellular signaling events which lead to changes in gene expression. These changes ultimately cause alterations in macromolecular synthesis, synaptic transmission, and structural architecture which support central sensitization, a process required for the establishment of long-term pain states. Epigenetic mechanisms are essential for long-term synaptic plasticity and modulation of gene expression. This is because epigenetic modifications are known to regulate gene transcription by aiding the physical relaxation or condensation of chromatin. These processes are therefore potential regulators of the molecular changes underlying permanent pain states. A handful of studies have emerged in the field of pain epigenetics; however, the field is still very much in its infancy. This chapter draws upon other specialties which have extensively investigated epigenetic mechanisms, such as learning and memory and oncology. After defining epigenetics as well as the recent field of "neuroepigenetics" and the main molecular mechanisms involved, this chapter describes the role of these mechanisms in the synaptic plasticity seen in learning and memory, and addresses those epigenetic mechanisms that have been linked with the development of acute and prolonged pain states. Finally, the idea that long-lasting epigenetic modifications could contribute to the transition from acute to chronic pain states by supporting maladaptive molecular changes is discussed."

Gerber LH, Shah J, Rosenberger W et al. 2015. Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects With Chronic Myofascial Pain. PM R. [Feb 4 Epub ahead of print.] "Dry needling reduces pain and changes MTrP status. Change in trigger point status is associated with a statistically and clinically significant reduction in pain. Reduction of pain is associated with improved mood, function, and level of disability."

Gerber LH, Sikdar S, Armstrong K et al. 2013. A Systematic Comparison Between Subjects with No Pain and Pain Associated with Active Myofascial Trigger Points. PM R. 5(11):931-938. "We evaluated adults with MPS and active (painful) MTrPs and those without pain. Subjects in the "Active" ('A') group had at least one active MTrP with spontaneous pain which was persistent, lasted more than 3 months and had characteristic pain on palpation. Subjects in the "No pain" ('Np') group had no spontaneous pain. However, some had discomfort on MTrP palpation (latent MTrP) while others in the Np group had no discomfort on palpation of nodules or had no nodules….Each participant underwent range of motion (ROM) measurement, 10-point manual muscle test, and manual and algometric palpation. The latter determined the pain/pressure threshold using an algometer of 4 pre-determined anatomical sites along the upper trapezius. Participants rated pain using a verbal analogue scale (0-10); completed the Brief Pain Inventory and Oswestry Disability Scale (ODS), which included a sleep sub-scale; Short Form 36(SF36) and the Profile of Mood States (POMS)….There were 24 in the 'A' group (mean 36yrs, 16 women) and 26 in the 'Np' group (mean 26yrs, 12 women). Subjects in group 'A' differed from 'Np' in number of latent MTrPs…; asymmetrical cervical ROM…; in all pain reports…; algometry…; POMS…; SF36…and ODS….A systematic musculoskeletal evaluation of people with MPS reliably distinguishes them from subjects with no pain. The two groups are significantly different in their physical findings and self-reports of pain, sleep disturbance, disability, health status and mood. These findings support the view that a "local" pain syndrome has significant associations with mood, health-related quality of life and function."

Gerbershagen HJ. 2013. [Transition from acute to chronic postsurgical pain: Physiology, risk factors and prevention.] Schmerz. [Feb 2 Epub ahead of print]. [Article in German] "Chronic postsurgical pain (CPSP) is defined as pain persisting for longer than 3 months postoperatively. The frequency of occurrence ranges from 5 % to 60 % in all types of surgery and 1-3 % of patients with CPSP will suffer from severe pain and pain-related interference with daily activities. The pathological mechanisms which lead to the development of CPSP are complex and have not yet been analyzed. Neuropathic pain after surgical nerve lesions has been reported. Many patients with CPSP, however, do not present with any neuropathic pain characteristics. Peripheral and central sensitization are the essential mechanisms of the development of pain chronicity in the postoperative period. As treatment of CPSP is demanding it is attempted to prevent central sensitization before CPSP develops." [It would be wise to assess each post-surgical patient for developing TrPs in a follow-up exam at least a month after surgery. DJS]

Gerdes N, Farin E. 2016. [Burdens at admission, short-term effects and predictors of health status at discharge among 1803 patients with fibromyalgia syndrome]. Rehabilitation (Stuttg);55(5):305-311. [Article in German] In rehabilitation research, analyses of change between pre- and post-measurement values should be accompanied by assessments of severity of rehabilitation status at discharge because even good improvements do not necessarily mean that a patient has been rehabilitated successfully.

Gerdle B, Ghafouri B, Ernberg M et al. 2014. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res.7:313-326. "These results indicate that peripheral muscle alterations are parts of the activated pain mechanisms in common chronic pain conditions. Muscle alterations have been reported in fibromyalgia syndrome and chronic widespread pain, but more studies are needed before definite conclusions can be drawn. For other substances, results are inconclusive across studies and patient groups."

Gerdle B, Larsson B, Forsberg F et al. 2013. Chronic Widespread Pain: Increased Glutamate and Lactate Concentrations in the Trapezius Muscle and Plasma. Clin J Pain. [Jul 24 Epub ahead of print]. "The present study supports the suggestion that aspects of pain and central alterations in CWP/FM are influenced by peripheral tissue alterations."

Gerhardt A, Eich W, Janke S et al. 2015. Chronic widespread back pain is distinct from chronic local back pain: Evidence from quantitative sensory testing, pain drawings, and psychometrics. Clin J Pain. [Sep 16 Epub ahead of print.] "Even after long duration CLP (chronic localized pain) presents with a local hypersensitivity for PPT (pressure pain threshold), suggesting a somatotopically specific sensitization of nociceptive processing. However, CWP (chronic widespread pain) patients show widespread ongoing pain and hyperalgesia for different stimuli that is generalized in space, suggesting the involvement of descending control systems, as also suggested for FMS patients. Because mechanisms in non-specific chronic back pain with CLP and CWP differ, these patients should be distinguished in future research and allocated to different treatments."

Germano Maciel D, Trajano da Silva M, Rodrigues JA et al. 2018. Low-level laser therapy combined to functional exercise on treatment of fibromyalgia: a double-blind randomized clinical trial. Lasers Med Sci. [Jun 21 Epub ahead of print] "This study aims to investigate the effects of low-level laser therapy (LLLT) combined to a functional exercise program on treatment of FM....In conclusion, the beneficial effects of functional exercise were not improved by combination with LLLT."

Germanowicz D, Lumertz MS, Martinez D et al. 2006.  Sleep disordered breathing concomitant with fibromyalgia syndrome.  J Bras Pneumol. 32(4):333-338.  “…the more than ten-fold higher proportion of fibromyalgia cases seen in this sample supports the hypothesis that there is an association between sleep disordered breathing and fibromyalgia syndrome.

Gerster, J. C. and A. Hadj-Djilani. 1984. Hearing and vestibular abnormalities in primary fibromyalgia syndrome. J Rheumatol 11(5):678-680.

Gervais Tougas G. 1999. The autonomic nervous system in functional bowel disorders. Can J Gastroenterol 13 Suppl A:15A-7A.  [ED, THIS NOTATION IS CORRECT]

Gerwin R. 2017. Trigger point diagnosis: At last, the first word on consensus. Pain Med. [Sep 23 Epub ahead of print]

Gerwin R. 2013. Are peripheral pain generators important in fibromyalgia and chronic widespread pain? Pain Medicine. 14:777-778. "Pain is not a simple sensation, and is rarely the result of a disorder in one system only. It is complex, involving multiple interactions. CWPS and FM cannot be considered to be solely a disorder of central pain modulation, and perhaps not even primarily so. Pain is the outcome of a complex interplay between the central modulation and peripheral pain input. That balance between inhibition and facilitation of incoming pain impulses determines the pain that we experience, as shown when descending pain modulation shifts from inhibition to facilitation following sustained isometric contraction sufficient to cause muscle nociception in FM patients."

Gerwin R. 2012. Botulinum Toxin Treatment of Myofascial Pain: A Critical Review of the Literature. Curr Pain Headache Rep. [Jul 10 Epub ahead of print]. "This is a review of literature relevant to the treatment of myofascial pain syndrome by botulinum injections. The objective is to critically review the studies to see if they are appropriately designed, conducted, and interpreted to provide guidance in the management of myofascial pain. The intent is to better understand the mixed results that these studies have provided. A search was made utilizing PubMed for literature relevant to the use of botulinum toxin in the treatment of myofascial pain. All identifiable series were reviewed, including open label, single-blinded and double-blinded studies, randomized and controlled, or not. In general, small case series of only a few patients were not included unless they made a relevant point and there were no available randomized studies or larger studies.... Problems that were common to the studies were robust placebo responders, incomplete treatment of a regional myofascial pain syndrome, inappropriate or confounding control populations or treatments, and inappropriate time periods for assessment of outcomes, or misinterpretation of the time-frame of action of botulinum toxin. The studies of the effect of botulinum toxin treatment of myofascial trigger points have had mixed results. However, few studies have been designed to avoid many of the pitfalls associated with a trial of botulinum toxin treatment of trigger points. Better-designed studies may give results that can be used to guide practice based on reliable evidence. At the present time, one must conclude that the available evidence is insufficient to guide clinical practice."

Gerwin R. 2010. Myofascial pain syndrome: here we are; where must we go? J Musculoskel Pain. 18(4):329-347.

"MPS was first defined clinically by Janet Travell, MD, and later by David Simons, MD. Pain neurophysiology has only recently provided the basis for understanding the sensorimotor manifestations of MPS. This article reviews the current state of knowledge concerning MPS. MPS is a form of myalgia characterized by local regions of muscle hardness and tenderness that cause referred pain. The signature feature is the trigger point, a tender, taut band of muscle that can be painful spontaneously or when stimulated. The active trigger point has identifiable pathophysiologic changes. Levels of substance P, calcitonin gene related peptide, bradykinin, and assorted cytokines, are elevated, indicating a chemical inflammation. Trigger point milieu pH is low, about pH 5, consistent with hypoxia and ischemia. Persistent, low-amplitude, high-frequency electrical discharges that look like endplate potentials characteristic. The taut band can be visualized using high definition ultrasonograpy and magnetic resonance sonography. Central scanning. The role of MPS in headache and pelvic pain has been extensively studied in the last few years. Although great progress has been made, studies are still needed to substantiate the energy crisis hypothesis of trigger point formation, to understand the nature of sustained muscle contraction that forms the taut band and of referred pain in humans, and to develop a more rationale and effective treatment."
"Nociceptive activity from TrPs activates spinal cord dorsal horn neurons and sensitizes the central nervous system, causing central sensitization, hyperalgesia, and referred pain. Muscle weakness without atrophy occurs due to TrP-induced motor inhibition. Restricted range of motion occurs because of the shortening of the contracted taut band, and perhaps because of pain. The range of motion in hypermobile individuals must be interpreted cautiously, because it can appear to be normal, but can still be restricted. Impaired reciprocal inhibition results in co-contraction of agonists and antagonists, thus interfering with fine motor control and coordination. Autonomic disturbances can accompany TrP activation leading to changes in skin temperature and color, piloerection (goosebumps), and lacrimation (tearing)….The clinically evident progression from a non-tender taut band to a tender taut band suggests that the first change in muscle is the development of the contracted, taut group of muscle fibers that can become painful when sufficiently stressed."
"Myofascial pain syndrome presents as acute and chronic muscle pain….It may be regional or widespread. It may be accompanied by a sensory component of parasthesias or dysesthesias. MPS may persist long after the initiating cause of pain has resolved. Thus, myofascial pain can be complex." "Muscles harboring a TrP are often weak. Weakness in affected muscles occurs without atrophy, and is not neuropathic or myopathic. It is rapidly reversible immediately on inactivation of the TrP, suggesting that it is caused by the inhibition of muscle action….a TrP in one muscle can inhibit effort or contractile force in another muscle." "The TrP causes a disordered recruitment of muscles that work together to produce an action." "Reciprocal inhibition, whereby contraction of one muscle is inhibited by the contraction of its antagonist muscle, is reduced or absent when the activated muscle contains a TrP. The lack of reciprocal inhibition causes co-contraction that reduces the quality of movement and leads to clumsiness and an incoordination of fine movement." "The range of motion around a joint moved by muscles with TrPs is often limited. The end range may be painful, but limitation of the range may be painless unless the patient is pushed to move beyond comfort. Limitation of range of motion is not a reliable indicator of the presence of a TrP in persons who are hypermobile…. Changes in spatial distribution also occur with muscle contraction, the changes correlating with the duration of contraction. This suggests that a more long-lasting nociceptive irritant like a TrP would also cause a functional spatial reorganization of muscle activity….The TrP is a tender focus in muscle, the region of tenderness always located on the taut band. The region of greatest hardness is usually also the region of greatest tenderness. A tender TrP always means that there is hyperalgesia or allodynia."
"Miniature endplate potentials are thought to be the result of spontaneous release of acetylcholine from motor nerve potentials….It is now clear that motor endplates are more widely distributed throughout the muscle than just the endplate zone….A greater endplate activity and consequently greater focal muscle sarcomere compression can be thought of as being associated with greater local muscle injury and local release of nociceptive substances." "It is likely that TrPs are first formed as latent TrPs and then become tender as muscle is activated. Latent TrPs exist without spontaneous pain. Furthermore, TrP tenderness does not occur except in regions of muscle hardness, but regions of muscle hardness occur without local or referred pain. Hence, muscle hardness or the taut band that occurs in the absence of pain may be the first abnormality, and the active TrP is a more activated TrP." "Current thinking in keeping with the expanded integrated hypothesis of the TrP is that localized ischemia is associated with the acute development and maintenance of the TrP. Localized ischemia results from capillary compression within the taut band. In turn, the release of vasodilating substances such as calcitonin gene-related peptide (CGRP) and substance P leads to localized non-inflammatory edema that further compresses capillaries. The initial change in the muscle associated with the TrP seems to be a motor abnormality, the development of the taut band."
"Sympathetic modulation of the SEA is the most important concept because of the important role the sympathetic nervous system plays in maintaining the abnormal electrical activity at the TrP. A post-synaptic muscle dysfunction that increases intracellular calcium concentration through a leaky ryanidine receptor calcium channel on the sarcoplasmic reticulum membrane or through adrenergic-mediated second-messenger systems involving protein kinase C and cyclic adenosine monophosphate (cAMP), initiating actin-myosin interaction, may also result in muscle fibril contraction….Calcium channel activity is important in the generation of TrP endplate noise…." "The association of endplate noise and the trigger zone has led to the suggestion that the trigger zone is where the endplate zone is located and that is in mid-belly of the muscle. However, the muscle mid-belly is not always obvious and depends on the specific anatomy of the muscle." "The myofascial trigger zone or region is hypoxic, a region of severe oxygen desaturation at the core surrounded by a region of increased oxygenation, consistent with capillary compression and ischemia. The core is ischemic and the surrounding zone hyperemic. Temperature studies of the trigger zone showed an increase in temperature in the TrP region, consistent with a hyperemic outer area but inconsistent with a hypoxic trigger zone core." "TrP tenderness is associated with central sensitization and hypersensitivity, as is the case with other tissues….Central sensitization is the mechanism through which referred pain occurs….One of the consequences of central sensitization is the activation of otherwise ineffective (sometimes called 'sleeping') synaptic connections from one afferent nerve fiber to many recipient nociceptive neurons. A single dorsal horn neuron will thus respond to a larger pool of afferent fiber connections, thereby greatly expanding its receptive field." "The most common referred pain patterns are within the same or adjacent spinal segments as that of the primary sensory nerve. Thus, TrPs in muscles innervated predominantly by the C5 nerve root refer pain largely to the C5 dermatome and myotome, overlapping into the C4 and C6 innervated areas. Because muscle innervation is relatively constant, segmental referred pain patterns tend to be relatively constant from one person to another….The activation of latent TrPs in one muscle results in increased motor activity in a distant muscle latent TrP in the same segmental level." "The segmental spread of referred pain can also be bilateral." "In summary, central sensitization and widespread pain referral is clinically important because individuals who have had seemingly local injury producing persistent pain can develop extraordinarily widespread pain with hyperalgesia or allodynia that appears to involve most of the body." "The proposal discussed herein is that muscle overuse, or bio-mechanical stress, is the cause of the TrP….Supramaximal muscle contraction or overloaded eccentric contraction can damage muscle and lead to pain, including delayed onset muscle soreness. Repetitive strain is a variant of muscle overload and is thought to have the same effect….The maintenance of fixed positions for long periods of time and sustained contraction of muscle as a result of emotional stress (anxiety, fear, and depression) are also thought to produce muscle overuse….There has long been a concern about the overlap of FMS and MPS, a concern now resolved with the understanding that FMS is a central pain disorder and MPS has a major central hypersensitization component. Therefore, it is not surprising that there are TrPs at many if not all of the sites selected for tender point assessment in FMS and that TrPs present as a comorbid finding in FMS can contribute to pain in FMS. Thus, the concurrence of the two conditions in individual patients with clinical pain syndromes is to be expected. Nearly one-quarter of patients with chronic cervical myofascial pain met the criteria for FMS. An earlier study found that 75 percent of subjects with FMS had clinically significant MPS. TrPs may be a peripheral pain generator initiating or sustaining FMS, or may occur secondarily to the development of central sensitization in FMS. No study has looked at the effect of treating TrPs on comorbid FMS."
"….the hyperirritable "nodule" does not have to be a palpable nodule at all. However, the taut band is a constant finding in active and latent TrPs, and is the only consistent objective finding on physical examination." "Dommerholt and Gerwin (unpublished data) found that identification of a taut band, tenderness of the taut band, and reproduction of the patient's pain were sufficient to guide effective treatment and presented this concept at the International Myopain Congress in Italy in 1998." [This is the International Myopain President's Address from the Myopain Congress 2010]

Gerwin RD. 2016. Myofascial trigger point pain syndromes. Semin Neurol. 6(5):469-473. "Myofascial pain syndromes caused by trigger points (TrPs) in muscle are a common cause of local and generalized pain. Trigger points are hyperirritable zones in contracted bands of muscle, thought to be caused by muscle overload or stress. Stress TrPs have characteristic electromyographic features, and can be visualized with ultrasound and magnetic resonance elastography. Trigger point needling or injection can be effective in inactivating TrP, but correcting triggers (activating/perpetuating factors) is also critical."

Gerwin RD. 2014. Diagnosis of Myofascial Pain Syndrome. Phys Med Rehabil Clin N Am. 25(2):341-355. "Myofascial pain is one of the most common causes of pain. The diagnosis of myofascial pain syndrome (MPS) is made by muscle palpation. The source of the pain in MPS is the myofascial trigger point, a very localized region of tender, contracted muscle that is readily identified by palpation. The trigger point has well-described electrophysiologic properties and is associated with a derangement of the local biochemical milieu of the muscle. A proper diagnosis of MPS includes evaluation of muscle as a cause of pain, and assessment of associated conditions that have an impact on MPS."

Gerwin RD. 2013. Chronic Pain Perspectives: Diagnosing fibromyalgia and myofascial pain syndrome: A guide. J Fam Pract. 62(12 Suppl 1):S19-25. "The instruments and physical exam techniques described here will help you to diagnose these 2 common soft-tissue pain conditions."

Gerwin RD. 2010. Fibromyalgia Tender Points at Examination Sites Specified by the American College of Rheumatology Criteria Are Almost Universally Myofascial Trigger Points. Curr Pain Headache Rep. [Oct 27 Epub ahead of print]. [Until FM researchers realize that most of the symptoms they are describing as fibromyalgia-related are actually caused by myofascial trigger points, their conclusions are suspect and resources are being wasted. DJS]

Gerwin RD. 1997.  Myofascial pain syndromes in the upper extremity.  J Hand Ther. 10(2):130-136.  “Myofascial pain syndromes of the upper extremity are common causes of pain that may follow trauma and are associated with acute or chronic musculoskeletal stress.  The syndromes are characterized by the presence of the myofascial trigger point, a physical finding that is reliably identified by palpation.  Local and referred pain are hallmarks of the syndrome, and the referred pain patterns may mimic such conditions as radiculopathy and nerve entrapment syndromes.  Treatment is directed toward inactivating the myofascial trigger point, correcting underlying perpetuating factors, and restoring the normal relationships between the muscles of the affected functional motor units.”

 

Gerwin RD. 1994. Neurobiology of the myofascial trigger point. Baillieres Clin Rheumatol. 8(4):747-762.  “The clinical phenomenon of the MTrP is accessible to any clinician who takes the time to learn to palpate skeletal muscle gently and carefully, and who is willing to learn the functional anatomy necessary to understand the regional spread of MTrPs through functional muscle units (Travell and Simons, 1992).”  “…researchers in the field of pain have given us an understanding of the basis for the hyperalgesia, allodynia and the previously difficult-to-understand finding of referred pain zones that we see daily in our patients.”

Gerwin R. 2007.  Trigger points: a comprehensive hypothesis of trigger point formation.  J Musculoskel Pain 15 (Supp 13):12 item 14.  [Myopain 2007 Poster]  Dr. Gerwin’s hypothesis may fill in the missing elements in the formation of myofascial trigger points (MTPs).  We did not have an explanation for the excess release of acetylcholine, the excess release of calcium, and the excessive motor endplate noise, nor did we understand why the taut band forms.  These phenomenon could be explained by a dysfunctional ryanodine receptor calcium channel.  This dysfunctional ion channel could promote the excessive calcium release from the sarcoplasmic reticulum, resulting in persistent muscle fiber contraction.  Gates in the cell wall, like tiny airlocks in a space station, allow charged particles such as calcium, potassium and other minerals to flow in and out of the cell membrane and affect the interior metabolism of the cell.  The pathways are called ion channels.  An illness caused by dysfunction of the gate mechanism is called a channellopathy.   This important piece of the puzzle indicates that myofascial pain due to trigger points could be a channellopathy.  Dysfunctional mitochondria and/or second messenger dysfunction metabolically upstream could also be responsible or be associated with the ryanodine dysfunction. [I found this to be one of the most exciting revelations at the Myopain ‘07 Congress, offering great hope to those of us with myofascial pain.  This offers a whole new way of looking at myofascial pain, and perhaps a whole new way of treating it.  I hope researchers will take note and mobilize forces to investigate this. DJS]

Gerwin R. 2004.  Differential diagnosis of trigger points.  J Musculoskeletal Pain 12(3/4):23-28.   “Trigger points pain can have many different causes that must be identified and treated specifically.”

Gerwin RD. 2005.  A review of myofascial pain and fibromyalgia—factors that promote their persistence.  Acupunct Med. 23(3):121-134.  Fibromyalgia and myofascial pain are common and different conditions, although they may occur in the same patient.  “Fibromyalgia is a chronic, widespread muscle tenderness syndrome, associated with central sensitization.  It is often accompanied by chronic sleep disturbance and fatigue, visceral pain syndromes like irritable bowel syndrome and interstitial cystitis.  Myofascial pain syndrome is an overuse or muscle stress syndrome characterized by the presence of trigger points in muscle.”  It is important to uncover the cause of chronic muscle pain so that treatment will be effective.  “Chronic myalgia may not improve until underlying precipitating or perpetuating factor(s) are themselves managed.”  These causes may include structural and metabolic conditions.  If the underlying  conditions are brought under control, the chronic myalgia may resolve.

Gerwin RD, Dommerholt J, Shah JP. 2004.  An Expansion of Simons’ integrated hypothesis of trigger point formation.  Curr Pain Headache Rep 8:468-475.  This paper further expounds on the mechanism of TrP formation explained in Simons Travell and Simons 1999 in the light of new research.  Individual irritating substances released at the motor endplate have been sampled during the TrP twitch response and subjected to microanalysis.  This research further substantiates the release of muscle damaging biochemicals and a significant drop in pH at the TrP site.  The pH drop alone is sufficient to cause a change in the nociceptive milieu, and the addition of proinflammatory mediators such as substance P, bradykinin and cytokines may additionally aggravate this change.  The continual pain barrage can affect central nervous system plasticity, resulting in hyperalgesia and allodynia as well as referred pain.

Gerwin RD. 1993.  The management of myofascial pain syndromes.  Jour Musculoskel Pain 1(3/4):83-94.  “MPS is a condition which is treatable by eliminating the specific trigger points that are the immediate cause of pain, and correcting those factors that predispose to recurrence.”

Gerwin, R. D. and D. Duranleau. 1997. Ultrasound identification of the myofascial trigger point. Muscle Nerve 20:767-768. 

Gerwin, R. D., S. Shannon, C. Z. Hong, D. Hubbard and R. Gevirtz.  1997.  Interrater reliability in myofascial trigger point examination.  Pain 69(1-2):65-73. 

Ghanbari A, Askarzadeh S, Petramfar P et al. 2015. Migraine responds better to a combination of medical therapy and trigger point management than routine medical therapy alone. NeuroRehabilitation. 37(1):157-163. "The combined PRT (positional release therapy)/medical therapy is more effective than the medical therapy alone. Thus, the combination of PRT and medical therapy is suggested as a treatment choice for patients with migraine headache."

Ghanbari A, Rahimijaberi A, Mohamadi M et al. 2012. The effect of trigger point management by positional release therapy on tension type headache. NeuroRehabilitation. 30(4):333-339. Both positional release therapy for trigger points and routine medical therapy were equally effective in treatment of tension type headache. [This could vary tremendously in regards to control of perpetuating factors, the skill of the practitioner, and the type of routine medical therapy, as we live in a world where even the recognition of trigger points is not routine. DJS]

Ghavidel-Parsa B, Bidari A, Amir Maafi A et al. 2015. The iceberg nature of fibromyalgia burden: The clinical and economic aspects. Korean J Pain. 28(3):169-176. "While our understanding of this debilitating disorder is limited, diagnosis and treatment of this condition is very difficult, even in the hands of experts. Due to the nature of disease, where patients experience invalidation by medical services, their families and societies regarding the recognition and management of disease, direct, indirect and immeasurable costs are considerable. These clinical and economic costs are comparable with other common diseases, such as diabetes, hypertension and osteoarthritis, but the latter usually receives much more attention from healthcare and non-healthcare resources. Present alarming data shows the grave and "iceberg-like" burden of FM despite the benign appearance of this disorder and highlights the urgent need both for greater awareness of the disease among medical services and societies, as well as for more research focused on easily used diagnostic methods and target specific treatment." Free PMC Article

Ghazan-Shahi S, Towheed T, Hopman W. 2012. Should rheumatologists retain ownership of fibromyalgia? A survey of Ontario rheumatologists. Clin Rheumatol. [May 2 Epub ahead of print]. "Key findings were: (1) 71 % believe that rheumatologists should not retain ownership of fibromyalgia, (2) 55 % believe that fibromyalgia is primarily a psychosomatic illness as opposed to a physical illness, (3) 89 % believe that the family physician should be the main care provider for these patients, and (4) rheumatologists who consider fibromyalgia to be a physical illness were also significantly more likely to believe that rheumatologists should retain ownership of this disease…and were more likely to continue managing these patients in their practice …. The majority of Ontario rheumatologists do not wish to retain ownership of fibromyalgia. However, most of them continue to manage these patients, even though they believe that the family physician should be the main care provider for patients with fibromyalgia. Rheumatologists may be providing care to these patients primarily because this care is not available to them from their primary care physicians."

Ghione S, Del Seppia C, Mezzasalma L et al. 2004.  Human head exposure to a 37 Hz electromagnetic field: Effects on blood pressure, somatosensory perception, and related parameters. Bioelectromagnetics 25(3):167-175. Specific electromagnetic field exposure can alter pain sensitivity in human beings.

Giacomelli C, Talarico R, Bombardieri S et al. 2013. The interaction between autoimmune diseases and fibromyalgia: risk, disease course and management. Expert Rev Clin Immunol. 9(11):1069-1076. "Fibromyalgia (FM) is a common non-autoimmune rheumatologic disease with a wide range of symptoms that worsen the clinical status of patients. Several authors have tried to identify a putative autoimmune biomarker but, unfortunately, without positive results. Moreover, the altered pain perception characteristic of FM patients is similar in other autoimmune rheumatologic and non-rheumatologic diseases, in fact the pain in FM is not strictly tied to an organic disease; the perception and the severity of it are comparable with those of autoimmune conditions, for example, the polymyalgia rheumatica. In this review, we focus on the FM comorbidities, especially related to autoimmune rheumatologic and non-rheumatologic conditions". [This review from Italy clarifies, once again, that fibromyalgia is not itself an auto-immune disease, but can co-exist with auto-immune diseases. The pain of FM is as severe as many autoimmune illnesses. They do not grasp the trigger point generation of the "FM" pain and dysfunction, and that trigger points can generate pain and dysfunction in any illness. DJS]

Giamberardino MA, Affaitati G, Costantini R. 2010. Visceral referred pain. J Musculoskel Pain. 18(4):403-410. "Visceral referred pain occurs in somatic areas neuromerically connected with the affected organs where secondary hyperalgesia takes place mostly in deep body wall tissues, extending to superficial layers in repeated/prolonged visceral processes. When two internal organs sharing part of their central sensory projection are affected, visceral pain and referred hyperalgesia from each organ are significantly enhanced ('viscero-visceral hyperalgesia'). In this case, treatment of one visceral condition significantly improves symptoms from the other. Referred phenomena are mainly sustained by central sensitization processes, involving viscero-somatic or viscero-visceral-somatic convergent neurons, as shown by electrophysiological studies in animal models. A contribution by viscero-somatic reflexes is also present, which would account for the trophic changes of deep body wall tissues that often accompany the hyperalgesia. The expression of visceral referred pain is reduced with the aging process, which renders diagnosis more difficult in the elderly, increasing the risks in life-threatening conditions. Some of the contributing mechanisms may include age-related impaired A-Delta fiber function and a reduction in the content and turnover of neurotransmitter systems involved in nociception..... Visceral referred pain and accompanying phenomena are being increasingly understood as regards their pathophysiology. This opens new avenues for treatment strategies that are more mechanism-based and not purely symptomatic."[As it is important to understand the concepts of viscero-somatic and somato-visceral referred pain, it is also important to understand how visceral pain can lead to central sensitization. As this article demonstrates, even advanced age can lead to referred visceral pain. DJS]

Giamberardino MA, Affaitati G, Fabrizio A et al. 2011. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 25(2):185-198. "This article reviews the available published knowledge about the diagnosis, pathophysiology and treatment of myofascial pain syndromes from trigger points. Furthermore, epidemiologic data and clinical characteristics of these syndromes are described, including a detailed account of sensory changes that occur at both painful and nonpainful sites and their utility for diagnosis and differential diagnosis; the identification/diagnostic criteria available so far are critically reviewed. The key role played by myofascial trigger points as activating factors of pain symptoms in other algogenic conditions - headache, fibromyalgia and visceral disease - is also addressed. Current hypotheses on the pathophysiology of myofascial pain syndromes are presented, including mechanisms of formation and persistence of primary and secondary trigger points as well as mechanisms beyond referred pain and hyperalgesia from trigger points. Conventional and most recent therapeutic options for these syndromes are described, and their validity is discussed on the basis of results from clinical controlled studies."

Giamberardino MA, Affaitati G, Fabrizio A et al. 2011. Effects of Treatment of Myofascial Trigger Points on the Pain of Fibromyalgia. Curr Pain Headache Rep. [May 5 Epub ahead of print]. "FMS is mainly rooted in the central nervous system, while TrPs have a peripheral origin. However, the nociceptive impulses from TrPs may have significant impact on symptoms of FMS, probably by enhancing the level of central sensitization typical of this condition. Several attempts have been made to assess the effects of treatment of co-occurring TrPs in FMS. We report the outcomes of these studies showing that local extinction of TrPs in patients with fibromyalgia produces significant relief of FMS pain. Though further studies are needed, these findings suggest that assessment and treatment of concurrent TrPs in FMS should be systematically performed before any specific fibromyalgia therapy is undertaken."

Giamberardino MA, Affaitati G, Martelletti P et al. 2015. Impact of migraine on fibromyalgia symptoms. J Headache Pain. 17(1):28. "Co-morbidity between fibromyalgia and migraine involves heightened somatic hyperalgesia compared to one condition only. Increased migraine frequency - with shift towards chronicity - enhances both hyperalgesia and spontaneous FMS pain, which is reversed by effective migraine prophylaxis. These results suggest different levels of central sensitization in patients with migraine, fibromyalgia or both conditions and a role for migraine as a triggering factor for FMS." [This confirms that co-existing conditions can add to central sensitization of FM, and that successfully dealing with migraine can ease the FM central sensitization. Migraine can also trigger FM central sensitization, so it is important to gain control of the initiating and perpetuating factors of the migraine, including trigger points. DJS]

Giannoccaro MP, Donadio V, Incensi A et al. 2013. Small nerve fiber involvement in patients referred for fibromyalgia. Muscle Nerve. [Dec 28 Epub ahead of print.] "Fibromyalgia (FM) is a chronic syndrome characterized by widespread pain often accompanied by other symptoms suggestive of neuropathic pain. We evaluated patients for small fiber neuropathy (SFN) who were referred for fibromyalgia (FM). Methods: We studied 20 consecutive subjects with primary FM. Patients underwent neurological examination, nerve conduction studies, and skin biopsies from distal leg and thigh. Results: Electrodiagnostic studies were normal in all patients. SFN was diagnosed in 6 patients by reduced epidermal nerve fiber density. These patients also showed abnormalities of both adrenergic and cholinergic fibers….A subset of FM subjects have SFN, which may contribute to their sensory and autonomic symptoms. Skin biopsy should be considered in the diagnostic work-up of FM."

Gilbert JW, Vogt M, Windsor RE et al. 2014. Vestibular dysfunction in patients with chronic pain or underlying neurologic disorders. J Am Osteopath Assoc. 114(3):172-178. "Individuals with vestibular dysfunction are at increased risk for falling. In addition, vestibular dysfunction is associated with chronic pain, which could present a serious public health concern as approximately 43% of US adults have chronic pain." Using a retrospective review of records, the authors found that: "Patients being treated with medications for chronic, noncancer pain or other underlying neurologic disorders may have a higher-than-average incidence of vestibular dysfunction. Baseline assessment and monitoring of the vestibular apparatus may be indicated for these patients.

Giordano D, Raso MG, Pernice C et al. 2015. Topical local anesthesia: focus on lidocaine-tetracaine combination. Local Reg Anesth. 8:95-100. "In recent years, the popularity of aesthetic and cosmetic procedures, often performed in outpatient settings, has strongly renewed interest in topical anesthetics. A number of different options are widely used, alone or in combination, in order to minimize the pain related to surgery. Moreover, interest in local anesthetics in the treatment of some painful degenerative conditions such as myofascial trigger point pain, shoulder impingement syndrome, or patellar tendinopathy is increasing. Numerous clinical trials have shown that lidocaine-tetracaine combination, recently approved for adults aged 18 or older, is effective and safe in managing pain. The present paper gives an overview of the recent literature regarding the efficacy and safety of lidocaine-tetracaine combination use." Free PMC Article

Giordano J, Schatman ME, Benedikter R. 2008. Pain care for a global community – Part 2. Pract Pain Manag. 8(7):65-69. Although this article is about the global undertreatment of chronic pain, the authors acknowledge a sad fact: "...the inadequacy of chronic pain treatment in the United States has been well documented, particularly with regard to the inappropriate exercise (i.e. under-use and/or incorrect/excessive use) of various diagnostic and therapeutic technologies, and a failure to provide integrative treatment approaches that address psycho-social, as well as biological aspects of pain."

Girasol CE, Dibai-Filho AV, de Oliveira AK et al. 2018. Correlation between skin temperature over myofascial trigger points in the upper trapezius muscle and range of motion, electromyographic activity, and pain in chronic neck pain patients. J Manipulative Physiol Ther. [Apr 6 Epub ahead of print] "Patients with chronic neck pain who had reduction of skin temperature over myofascial trigger points in the upper trapezius muscle had reduced cervical range of motion for flexion, reduced median frequency at rest and during isometric contraction, and increased root mean square at rest." [Travell and Simons mentioned change in conductivity in skin over trigger points. TPM Vol I ed 2 p 117. DJS]

Girschick HJ, Morbach H, Tappe D. 2009. Treatment of Lyme borreliosis. Arthritis Res Ther. 11(6):258. “Borrelia burgdorferi sensu lato is the causative agent of Lyme borreliosis in humans. This inflammatory disease can affect the skin, the peripheral and central nervous system, the musculoskeletal and cardiovascular system and rarely the eyes. Early stages are directly associated with viable bacteria at the site of inflammation. The pathogen-host interaction is complex and has been elucidated only in part. B. burgdorferi is highly susceptible to antibiotic treatment and the majority of patients profit from this treatment. Some patients develop chronic persistent disease despite repeated antibiotics. Whether this is a sequel of pathogen persistence or a status of chronic auto-inflammation, auto-immunity or a form of fibromyalgia is highly debated. Since vaccination is not available, prevention of a tick bite or chemoprophylaxis is important. If the infection is manifest, then treatment strategies should target not only the pathogen by using antibiotics but also the chronic inflammation by using anti-inflammatory drugs.”

Gist AC, Guymer EK, Ajani AE et al. 2017. Fibromyalgia has a high prevalence and impact in cardiac failure patients. Eur J Rheumatol. 4(4):245-249. "Chronic cardiac failure (CCF) shares several clinical features with fibromyalgia (FM), a syndrome of increased central sensitivity and musculoskeletal pain. FM frequently coexists with other chronic illness.....High prevalence of FM was found in patients with CCF. This was associated with increased likelihood of other comorbid central sensitivity syndromes and with poorer clinical outcomes." Free Article [The common FM perpetuating factor of insulin resistance may be a perpetuating factor for CCF. Patients with all chronic illnesses should be assessed for TrPs. Many symptoms might be treatable. DJS]

Gist AC, Guymer EK, Eades LE et al. 2017. Fibromyalgia remains a significant burden in rheumatoid arthritis patients in Australia. Int J Rheum Dis. [Mar 13 Epub ahead of print.] "FM continues to demonstrate a high prevalence in a population of RA patients. RA patients with FM have more symptoms of other chronic sensitivity syndromes in addition to FM. They have a lower quality of life outcome and higher medication use. This has important clinical implications in terms of diagnosis, response to therapy, prescribing choices and clinical outcomes."

Gittins R, Howard M, Ghodke A et al. 2017. The accuracy of a fibromyalgia diagnosis in general practice. Pain Med. [Jul 17 Epub ahead of print] Twenty-six patients diagnosed with FM in a chronic pain clinic of an academic medical center were matched by age and gender to a control group of people with other forms of chronic nonmalignant pain. Only three (11.5%) participants with a prior diagnosis of FM fulfilled the 1990 ACR diagnostic criteria, increasing to 38.5% when the 2010 criteria were applied; however, 46.1% of controls also met the revised diagnostic criteria. FM is commonly misdiagnosed: all patients with a working diagnosis should be reassessed and reviewed to ensure that the most appropriate treatment is provided.

Gladden RM, Martinez P, Seth P. 2016. Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid-Involved Overdose Deaths - 27 States, 2013-2014. MMWR Morb Mortal Wkly Rep. 65(33):837-843. From the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. "In March and October 2015, the Drug Enforcement Administration (DEA) and CDC, respectively, issued nationwide alerts identifying illicitly manufactured fentanyl (IMF) as a threat to public health and safety…. IMF is unlawfully produced fentanyl, obtained through illicit drug markets, includes fentanyl analogs, and is commonly mixed with or sold as heroin…. Starting in 2013, the production and distribution of IMF increased to unprecedented levels, fueled by increases in the global supply, processing, and distribution of fentanyl and fentanyl-precursor chemicals by criminal organizations …. Fentanyl deaths are not reported separately in national data.… Nationally, the number of fentanyl submissions and synthetic opioid deaths increased by 426% and 79%, respectively, during 2013-2014; among the 27 analyzed states, fentanyl submission increases were strongly correlated with increases in synthetic opioid deaths. Changes in fentanyl submissions and synthetic opioid deaths were not correlated with changes in fentanyl prescribing rates, and increases in fentanyl submissions and synthetic opioid deaths were primarily concentrated in eight states (high-burden states). Reports from six of the eight high-burden states indicated that fentanyl-involved overdose deaths were primarily driving increases in synthetic opioid deaths." Free Article [The increases in recent opioid overdose and death are driven by unlawfully produced street drugs, rather than from legal prescriptions to chronic pain patients. DJS]

Glass JM. 2010. Cognitive dysfunction in fibromyalgia syndrome. J Musculoskel Pain. 18(4):367-372. "Fibromyalgia syndrome (FMS) is characterized by chronic, widespread, musculoskeletal pain, but symptoms other than pain are common. Dyscognition is a term used to refer to subjective feelings and objective performance measures of cognitive dysfunction. In this paper, the evidence for dyscognition in FMS is reviewed. Dyscognition is a prevalent symptom among patients with FMS that can be very disruptive. Studies using self-report measures support patient reports of dyscognition, demonstrating perceived problems across a number of cognitive domains. Tests using performance-based measures of cognitive function also support patient reports of dyscognition. Furthermore, these tests have thus far revealed a pattern of impairment in working memory and attention/executive control as well as memory impairment. Dyscognition is a real and troubling symptom for many patients with fibromyalgia. However, the body of research on dyscognition in FMS is still quite small. More research is needed to understand the factors that contribute to dyscognition and treatment approaches that help with dyscognition and to understand the cognitive symptoms that are affected, including neuroimaging studies." "Although pain is the defining symptom, it is well known that other symptoms often accompany FMS, including fatigue, somatic complaints, mood disorders, and cognitive dysfunction. Researchers have used the term 'dyscognition' to refer to both self- reported cognitive problems and objective dysfunction seen on performance-based measures of cognition. Patients refer to the subjective experience of cognitive dysfunction as 'fibrofog,' and several studies point to the salience of this particular symptom. Memory and concentration problems are reported by many patients, following pain, stiffness, fatigue, and nonrestorative sleep as the most prevalent symptoms. When dyscognition problems are present, patients report that they are very disruptive." "Glass et al. found that FMS patients reported lower memory capacity, more negative change in memory, and more anxiety about memory performance than healthy age- and education-matched controls. Of interest was the fact that patients also reported more use of strategies to support memory while at the same time reporting lower self-efficacy over memory performance….Specifically, tests that focus on working memory and on executive control of attention, as well as tests of long-term verbal episodic and semantic memory, appear to be most likely to reveal dysfunction. Working memory is the ability to briefly store a small amount of information in mind while performing other mental operations….The evidence to date suggests that the aspect of working memory that is most affected in FMS is the ability to maintain attention or to manage the items in working memory, rather than with the simple storage of items for a brief period. Consistent with this view, FMS patients perform poorly on tests that involve attentional control and the ability to ignore distraction….suggest that FMS patients have a particular difficulty dealing with distraction or managing attention. This ability to manage distraction is part of a domain of cognitive abilities called executive function….In addition to working memory and attention control tests, several studies point to problems with memory function in FMS patients." "Dick et al. found that when pain was included as a covariate in their analyses, differences between FMS patients and controls became nonsignificant. These results suggest that the most important contributor to cognitive dysfunction in FMS is pain, but this is still very much a preliminary conclusion." [This article is a masterful presentation of what we know now about FM cognitive dysfunction. DJS]

Glass JM. 2009. Review of cognitive dysfunction in fibromyalgia: a convergence on working memory and attentional control impairments.  Rheum Dis Clin North Am. 35(2):299-311.  “Clinical and laboratory evidence confirm that dyscognition is a real and troubling symptom in fibromyalgia (FM), and that the cognitive mechanisms most affected in FM are working memory, episodic memory, and semantic memory.  Recent evidence provides further convergence on specific difficulty with attentional control.  Dyscognition in FM…does seem to be related to the level of pain.”  [Cognitive dysfunction is real in FM, and the need for adequate pain control is great. DJS]

Glass JM. 2006.  Cognitive dysfunction in fibromyalgia and chronic fatigue syndrome: new trends and future directions.  Curr Rheumatol Rep. 8(6):425-429.  “Fibromyalgia (FM) and chronic fatigue syndrome (CFS) patients often have memory and cognitive complaints.  Objective cognitive testing demonstrates long-term and working memory impairments.  In addition, CFS patients have slow information processing, and FM patients have impaired control of attention, perhaps due to chronic pain.  Neuroimaging studies demonstrate cerebral abnormalities and a pattern of increased neural recruitment during cognitive tasks.  Future work should focus on the specific neurocognitive systems involved in cognitive dysfunction in each syndrome.”

Glass JM, Park DC, Minear M et al. 2005.  Memory beliefs and function in fibromyalgia patients.  J Psychosom Res. 58(3):263-269.  “Among the patients, perceived capacity, achievement motivation, and self-efficacy were significantly correlated with objective memory performance on a recall task.”

Glass JM, Lyden AK, Petzke F et al. 2004.  The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals.  J Psychosom Res. 57(4):391-398.  “A subset of subjects developed symptoms of pain, fatigue, and mood changes after exercise deprivation.  This cohort was different from the individuals who did not develop symptoms in baseline measures of HPA axis, immune, and autonomic function.  We speculate that a subset of healthy individuals who have hypoactive function of the biological stress response systems unknowingly exercise regularly to augment the function of these systems and suppress symptoms.  These individuals may be at risk for developing chronic multisymptom illnesses when a ‘stressor’ leads to lifestyle changes that disrupt regular exercise.”

Glass JM, Lyden AK, Petzke F et al. 2004.  The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals.  J Psychosom Res 57(4):391-398.  “A subset of subjects developed symptoms of pain, fatigue, mood changes after exercise deprivation.  This cohort was different from the individuals who did not develop symptoms in baseline measures of HPA axis, immune, and autonomic function.  We speculate that a subset of healthy individuals who have hypoactive function of the biological stress response systems unknowingly exercise regularly to augment the function of these systems and suppress symptoms.  These individuals may be at risk for developing chronic multisymptom illnesses when a 'stress' leads to lifestyle changes that disrupt regular exercise.”

Glass JM, Williams DA, Fernandez-Sanchez ML et al. 2011. Executive Function in Chronic Pain Patients and Healthy Controls: Different Cortical Activation During Response Inhibition in Fibromyalgia. J Pain. [Sep 24 Epub ahead of print]. "FM patients show lower activation in the inhibition and attention networks and increased activation in other areas. Inhibition and pain perception may use overlapping networks: resources taken up by pain processing may be unavailable for other processes." The brain can be so occupied dealing with pain input that it can't handle other tasks. Multitasking can only go so far, especially if the brain is handling pain from multiple sources.

Gleitz M, Hornig K. 2012. [Trigger points - Diagnosis and treatment concepts with special reference to extracorporeal shockwaves]. Orthopade. 41(2):113-125. [German] "The 70-year-old trigger point theory has experienced a growing scientific confirmation and clinical significance as a consequence of recent muscle pain research....The most effective conventional forms of treatment are aimed at a direct mechanical manipulation of the trigger point as are new forms of therapy with focused and radial shockwaves. By using high pressures the focused shockwaves in particular are suitable to provoke local and referred pain and thus simplify the trigger point diagnosis....Overall, the shockwave therapy on muscles represents a confirmation and extension of the existing trigger point therapy. It seems to be suitable for treating functional muscular disorders and myofascial pain syndromes within the locomotor system."

Glissen Brown JR, Bernstein GR, Friedenberg FK et al. 2016. Chronic abdominal wall pain: An under-recognized diagnosis leading to unnecessary testing. J Clin Gastroenterol. [Aug 19 Epub ahead of print.] "Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after extensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett's sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities." [Trigger points are a common source of abdominal pain, and musts be considered in a differential diagnosis or as part of interactive diagnoses. DJS]

Gluszek, J., L. Szczesniak, F. Banaszak, A. Tykarski and T. Rychlewski.  1999. [No title available].  Pol Arch Med Wewn 101(3):191-6 [Polish].

Gockel U, Tolle T. 2007.  Fibromyalgic vs. neuropathic pain.  J Musculoskel Pain 15 (Supp 13):48 item 83.  [Myopain 2007 Poster]  “The pain experienced subjectively by FMS patients is conspicuously greater than that experienced by other patients with typical neuropathic complaints.  Furthermore, this pain is associated with more severe co-morbidities such as depression/anxiety and sleep disturbance.”

Godefroy JN, Adam V. 1989. [Importance of muscular pathology in differential diagnosis of tooth pain]. Rev Fr Endod. 8(4):35-42. [Article in French] "Pain can be something hazy and the way it occurs can make the practitioner doubt. Some toothaches are treated with root canal therapy or removal of the tooth (or teeth) when the etiology is myofascial pain dysfunction (MPD). This implies the need of a proper differential diagnosis between myofascial pain dysfunction and root canal pathology." [This has been known for much longer, but there are many dentists and oral surgeons who are still unaware. DJS]

Goebel A, Buhner S, Schedel R et al. 2008. Altered intestinal permeability in patients with primary fibromyalgia and in patients with complex regional pain syndrome. Rheumatology (Oxford). 47(8):1223-1227. FM patients in this study showed significant increased intestinal permeability.

Gold, D. R., S. Rogacz, N. Bock, T. D. Tosteson, T. M. Baum, F. E. Speizer and C. A. Czeisler. 1992.  Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses.  Am JPublic Health 82(7):1011-4.  

Goldenberg DL, Clauw DJ, Palmer RE et al. 2016. Opioid use in fibromyalgia: A cautionary tale. Mayo Clin Proc. [Mar 11 Epub ahead of print.] "Multiple pharmacotherapies are available for the treatment of fibromyalgia (FM), including opioid analgesics. We postulate that the mechanism of action of traditional opioids predicts their lack of efficacy in FM." After a search of computer databases "…using the search term opioid AND fibromyalgia…. We found no evidence from clinical trials that opioids are effective for the treatment of FM. Observational studies have found that patients with FM receiving opioids have poorer outcomes than patients receiving nonopioids, and FM guidelines recommend against the use of opioid analgesics. Despite this, and despite the availability of alternative Food and Drug Administration-approved pharmacotherapies and the efficacy of nonpharmacologic therapies, opioids are commonly used in the treatment of FM." [This paper will undoubtedly be used to deny patients medications. We need to be aware of such things, and also that there are NO studies in fibromyalgia patients who also have multiple other conditions, for which the FM amplification to cause amplified pain. Perhaps it is time to stop pushing the "three approved FM meds" (by doctors who have taken money by the manufacturers of these meds and others) for people with FM who find them ineffective and/or causing severe side effects, and for us to undertake some meaningful studies on opioids and patients interactive chronic illnesses. DJS]

Goldstein, L. B., F. C. Last and V. M. Salerno.  1997.  Prevalence of hyperactive digastric muscles during swallowing as measured by electromyography in patients with myofascial pain dysfunction syndrome.  Funct Orthod 14(3):18-22.

Gollwitzer H, Opitz G, Gerdesmeyer L et al. 2014. [Greater trochanteric pain syndrome.] Orthopade. 43(1):105-118. [Article in German] Greater trochanteric pain is one of the common complaints in orthopedics. Frequent diagnoses include myofascial pain, trochanteric bursitis, tendinosis and rupture of the gluteus medius and minimus tendon, and external snapping hip. Furthermore, nerve entrapment like the piriformis syndrome must be considered in the differential diagnosis. This article summarizes essential diagnostic and therapeutic steps in greater trochanteric pain syndrome. Careful clinical evaluation, complemented with specific imaging studies and diagnostic infiltrations allows determination of the underlying pathology in most cases. Thereafter, specific nonsurgical treatment is indicated, with success rates of more than 90 %. Resistant cases and tendon ruptures may require surgical intervention, which can provide significant pain relief and functional improvement in most cases.

Golmirzaie G, Holland LS, Moser SE et al. 2016. Time since inciting event is associated with higher centralized pain symptoms in patients diagnosed with Complex Regional Pain Syndrome. Reg Anesth Pain Med. 41(6):731-736. "Our findings suggest that the longer the patients have CRPS the more likely they are to report symptoms suggestive of centralized pain. These data may explain why some patients with a longer duration of CRPS do not respond to peripherally directed therapies."

Gonzalez-Perez LM, Infante-Cossio P, Granados-Nunez M et al. 2015. Deep dry needling of trigger points located in the lateral pterygoid muscle: Efficacy and safety of treatment for management of myofascial pain and temporomandibular dysfunction. Med Oral Patol Oral Cir Bucal. [Feb 7 Epub ahead of print.] This study from Spain attempted to discover "…whether deep dry needling (DDN) of trigger points (TPs) in the lateral pterygoid muscle (LPM) would significantly reduce pain and improve function, compared with methocarbamol/paracetamol medication…." They found that "…DDN of TPs in the LPM showed better efficacy in reducing pain and improving maximum mouth opening, laterality, and protrusion movements compared with methocarbamol/paracetamol treatment. No adverse events were observed with respect to DDN." Free Article

Gonzalez-Perez LM, Infante-Cossio P, Granados-Nunez M et al. 2012. Treatment of temporomandibular myofascial pain with deep dry needling. Med Oral Patol Oral Cir Bucal. [May 1 Epub ahead of print]. "Although further studies are needed, our findings suggest that deep dry needling in the trigger point in the external pterygoid muscle can be effective in the management of patients with myofascial pain located in that muscle."

Gonzalez-Roldan AM, Munoz MA, Cifre I et al. 2013. Altered psychophysiological responses to the view of others' pain and anger faces in fibromyalgia patients. J Pain. [Apr 25 Epub ahead of print]. "Our findings suggest that brain and cardiac activity elicited by viewing facial expressions of pain and anger in others is altered in fibromyalgia patients. This cognitive bias toward negative emotions could be used in clinical settings as a psychobiological marker during the assessment and treatment of fibromyalgia."

Gonzalez-Villar AJ, Pidal-Miranda M, Arias M et al. 2017. Electroencephalographic evidence of altered top-down attentional modulation in fibromyalgia patients during a working memory task. Brain Topogr. [Apr 10 Epub ahead of print] "In this study we recorded electroencephalographic activity in 32 women with FM and 30 matched controls while they performed a 2-back working memory task. We analyzed behavioural data, posterior alpha and midfrontal theta frequency power, and theta phase synchronization between midfrontal locations and the remaining scalp-recorded areas. Task performance was similar in patients and controls; however, time-frequency analysis showed a smaller decrease in the amplitude of the posterior alpha (related to attentional processing) and a smaller increase in midfrontal theta power (related to mental effort) in FM patients than in healthy controls. The FM patients also showed lower functional connectivity between midfrontal locations and rest of the scalp-recorded areas in the theta band (related to information transfer across distant brain regions when top-down control is required). To our knowledge, this is the first study relating alterations in oscillatory activity and impaired connectivity to attentional working memory complaints in FM patients. Reduced power in the theta band during performance of the task suggests that the medial frontal cortex may play an important role in the attentional deficits reported in FM."

Gonzalez-Villar AJ, Samartin-Veiga N, Arias M. Increased neural noise and impaired brain synchronization in fibromyalgia patients during cognitive interference. Sci Rep. 7(1):5841. "Results suggest higher neural noise and impaired local and distant neural coordination in the patients and support the neural noise hypothesis to explain dyscognition in FM." Free Article

Gooneratne NS, Vitiello MV. 2014. Sleep in older adults: Normative changes, sleep disorders, and treatment options. Clin Geriatr Med. 30(3):591–627. "Sleep disorders are common in older adults: Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. When considering insomnia symptoms, it is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter distinguished by the presence of significant daytime symptoms such as fatigue. Evaluation with a sleep diary and screening for comorbid conditions, especially mood disorders, is essential.… Treatment options include the following: sleep hygiene, which while helpful, has not been found to be effective when used as monotherapy; 180 cognitive-behavioral therapy for insomnia, which requires multiple sessions but can have sustained benefit; and pharmacotherapy with sedative-hypnotics, melatonin agonists, or anti-depressants. Patients with chronic insomnia that is resistant to treatment may benefit from a polysomnography to screen for other sleep disorders. If left untreated, insomnia can increase the risk of depression…. Sleep apnea…can increase the risk of cardiovascular disease and may nearly double the risk of cognitive impairment over a five year period. Diagnosis requires a polysomnography, however." [In-home polysomnography may miss sleep architectural problems and other barriers to restorative sleep. If chronic pain and chronic fatigue occur, in-lab polysomnography is required, with a 2nd session on CPAP to ensure that the CPAP itself is sufficient to provide restorative sleep, and that the CPAP is set with the optimal pressure. There may be multiple causes of sleep and fatigue in chronic pain patients, and taking care of one perpetuating factor, such as sleep apnea, may be insufficient to provide restorative sleep or such factors such as sleep fragmentation. The hunt for perpetuating factors must continue until restorative sleep is supplied. DJS]

Gordon CM, Andrasik F, Schleip R et al. 2016. Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach. J Bodyw Mov Ther. 20(3):614-622. "A statistically significant decrease in stiffness and increase in elasticity was observed post intervention for the treated side only, while pressure pain thresholds improved on the untreated side as well. Reports of pain significantly decreased after treatment, with gains being maintained at 1 and 13 months following treatment. Levels of suffering, stress, and quality of life revealed statistically significant improvement as well."

Gordon, D. A.  1999.  Chronic widespread pain as a medico-legal issue.  Baillieres Best Pract Res Clin Rheumatol 13(3):531-43.  

Gordon, N. P., P. D. Cleary, C. E. Parker and C. A. Czeisler.  1986.  The prevalence and health impact of shiftwork.  Am J Public Health 76(10):1225-8. 

Gormsen L, Bach FW, Rosenberg R et al. 2017. Differential pain modulation in patients with peripheral neuropathic pain and fibromyalgia. Scand J Pain. 3(3):116-123. "The results are consistent with the idea that peripheral neuropathic pain is primarily driven from damaged nerve endings in the periphery, while chronic fibromyalgia pain may be a central disorder with increased activity in pain-facilitating systems."

Gota CE1, Kaouk S, Wilke WS. 2015. Fibromyalgia and obesity: The association between Body Mass Index and disability, depression, history of abuse, medications, and comorbidities. J Clin Rheumatol. 21(6):289-295. This study from the Cleveland Clinic found that: "Compared with normal-weight patients, obese FM patients are more disabled, report more medical comorbidities, exercise less, have a higher incidence of abuse, report increased depressive symptoms, and take more medications for FM. Bivariate analysis showed association of increasing BMI with the Health Assessment Questionnaire Disability Index (not FM impact questionnaire) and depression. We confirm that the prevalence of overweight and obesity is high in FM and believe that physicians treating FM should… discuss weight loss with their FM patients. Even if increasing BMI is not intrinsic to FM, it contributes to poor mood and functional outcome and should be a treatment goal. [It would also help if the physicians looked into the possible causes of obesity in their FM patients, including co-existing conditions. DJS]

Gottrup H, Juhl G, Kristensen AD et al. 2004.  Chronic oral gabapentin reduces elements of central sensitization in human functional hyperalgesia. Anesthesiology 101(6):1400-1408.

Goucke CR. 2001.  Australian management strategies for oral opioid use in non-malignant pain. Eur J Pain 5 Suppl A:99-101.

Goudra B, Shah D, Balu G et al. 2017. Repetitive transcranial magnetic stimulation in chronic pain: A Meta-analysis. Anesth Essays Res. 11(3):751-757. "Use of rTMS improves the efficacy of conventional medical treatment in chronic pain patients. This treatment is not associated with any direct adverse effects. However, the duration and frequency of rTMS therapy is presently highly variable and needs standardization." Free Article

Goulart R Jr, Detanico D, Vasconcellos RP et al. 2013. Reduction mammoplasty improves body posture and decreases the perception of pain. Can J Plast Surg. 21(1):29-32. "Following mammoplasty, an improvement in body posture, primarily in the alignment of shoulders, trunk and pelvis, and a decrease in pain in the upper limbs and spine, were observed." Free Article

Govender C, Cassimjee N, Schoeman J et al. 2007.  Psychological characteristics of FMS patients.  J Musculoskel Pain 15 (Supp 13):55 item 98.  [Myopain 2007 Poster]  “The majority of subjects exhibited secure attachment and the results questions the existence of a single FMS-prone psychological profile.”

Gowans SE, Dehueck A. 2007.  Pool exercise for individuals with fibromyalgia.  Curr Opin Rheumatol. 19(2):168-173.  “Pool exercise can be an effective intervention for individuals with fibromyalgia.”  [One must be careful of the temperature of the pool and the type of exercise, especially if patients have co-existing myofascial TrPs. DJS]

Gowans SE, DeHueck A. 2004.  Effectiveness of exercise in management of fibromyalgia.  Curr Opin Rheumatol 16(2):138-42.  “Individuals with fibromyalgia also need to be able to access community exercise programs that are appropriate for them.  This may require community instructors to receive instruction on exercise prescription and progression for individuals with fibromyalgia.”  [ It is also vitally important that these individuals receive instruction on the dangers of repetitive exercise for individuals with co-existing CMP. DJS]

Graff-Radford SB, Bassiur JP. 2014. Temporomandibular Disorders and Headaches. Neurol Clin. 32(2):525-537. "Headache and temporomandibular disorders should be treated together but separately. If there is marked limitation of opening, imaging of the joint may be necessary. The treatment should then include education regarding limiting jaw function, appliance therapy, instruction in jaw posture, and stretching exercises, as well as medications to reduce inflammation and relax the muscles. The use of physical therapies, such as spray and stretch and trigger point injections, is helpful if there is myofascial pain."

Grahmann PH, Jackson KC 2nd, Lipman AG. 2004.  Clinician beliefs about opioid use and barriers in chronic nonmalignant pain.  J Pain Palliat Care Pharmacother. 18(2):7-28.  “There is increasing acceptance of opioids for most of the listed types of chronic nonmalignant pain, but the acceptance varies by types of pain syndromes.”

Grassi, W., P. Core, G. Corlino, F. Salaffi and C. Cervini. 1994. Capillary permeability in fibromyalgia.  J Rheumatol 21(7):1328-1331.

Grassini S, Nordin S. 2017. Comorbidity in migraine with functional somatic syndromes, psychiatric disorders and inflammatory diseases: A matter of central sensitization? Behav Med. 43(2):91-99. "The results showed (a) significant comorbidity in migraine with all FSSs, psychiatric disorders and inflammatory diseases, (b) significantly elevated scores on stress, burnout, anxiety, depression, and somatization, and (c) relatively high prevalence rates on almost all symptoms. Taken together, the results motivate future study of central sensitization as a mechanism underlying migraine."

Grau JW, Huang YJ. 2018. Metaplasticity within the spinal cord: Evidence brain-derived neurotrophic factor (BDNF), tumor necrosis factor (TNF), and alterations in GABA function (ionic plasticity) modulate pain and the capacity to learn. Neurobiol Learn Mem. [Apr 7 Epub ahead of print]

Graven-Nielsen T, Mense S, Arendt-Nielsen L. 2004.  Painful and non-painful pressure sensations from human skeletal muscle.  Exp Brain Res. [Epub ahead of print]  Specific nerve fiber contributions to peripheral pain.

Graven-Nielsen, T., K. S. Aspegren, K. G. Henriksson, M. Bengtsson, J. Sorensen, A. Johnson, B. Gerdle and L. Arendt-Nielsen.  2000.  Ketamine reduces muscle pain, temporal summation, and referred pain in fibromyalgia patients.  Pain 85(3):483-491.

Greaves MW, Wall PD. 1996.  Pathophysiology of itching.  Lancet 348(9032):938-940.  There is a strong central nervous system component to some forms of itch, and the neurotransmitter histamine is frequently involved.  [The connection between itch and pain is involved and still being explored. DJS]

Greco R, Gasperi V, Maccarrone M et al. 2010. The endocannabinoid system and migraine. Exp Neurol. [Mar 27 Epub ahead of print]. “The recently discovered endocannabinoid system (ECS), which includes endocannabinoids and the proteins that metabolize and bind them, has been implicated in multiple regulatory functions both in health and disease. Several studies have suggested that ECS is centrally and peripherally involved in the processing of pain signals. This finding is corroborated by the evidences that endocannabinoids inhibit, through a cannabinoid type-1 receptor (CB1R)-dependent retrograde mechanism, the release of neurotransmitters controlling nociceptive inputs and that the levels of these lipids are high in those regions (such as sensory terminals, skin, dorsal root ganglia) known to be involved in transmission and modulation of pain signals. In this review we shall describe experimental and clinical data that, intriguingly, demonstrate the link between endocannabinoids and migraine, a neurovascular disorder characterized by recurrent episodic headaches and caused by abnormal processing of sensory information due to peripheral and/or central sensitization. Although the exact ECS-dependent mechanisms underlying migraine are not fully understood, the available results strongly suggest that activation of ECS could represent a promising therapeutical tool for reducing both the physiological and inflammatory components of pain that are likely involved in migraine attacks.”

Green JS, Stanforth PR, Rankinen T et al. 2004.  The effects of exercise training on abdominal visceral fat, body composition, and indicators of the metabolic syndrome in postmenopausal women with and without estrogen replacement therapy: the HERITAGE family study.  Metabolism 53(9):1192-1196.  Exercise did not improve the Metabolic Syndrome status of these study participants.

Greenman, Philip E.  1996. Principles of Manual Medicine. Baltimore MD: Williams and Wilkins. Griffiths, R. D., C. J. Hinds and R. A. Little.  1999.  Manipulating the metabolic response to injury.  Br Med Bull 55(1):181-95.

Greisen J, Juhl CB, Grofte T et al. 2001.  Acute pain induces insulin resistance in humans.  Anesthesiology. 95(3):573-4  “...pain relief in stress states is important for maintenance of normal glucose metabolism.”  [Chronic pain patients may also be predisposed to insulin resistance.  DJS]

Gregoire S, Millecamps M, Naso L et al. 2016. Therapeutic benefits of the methyl donor S-adenosylmethionine (SAM) on nerve injury-induced mechanical hypersensitivity and cognitive impairment in mice. Pain. [Dec 22 Epub ahead of print.] "SAM attenuated SNI-induced mechanical hypersensitivity and reduced active avoidance of mechanical stimuli but had no effect on cold sensitivity or motor capacity. SAM completely blocked nerve injury-induced cognitive impairment and attenuated SNI-induced decreases in global DNA methylation in the frontal cortex. In summary, chronic oral administration of the methyl donor SAM attenuated sensory and cognitive symptoms associated with nerve injury in mice. These effects may be mediated, in part, through modulation of DNA methylation in the CNS by systemic administration of the methyl-donor SAM."

Grichnik, K. P. and F. M. Ferrante.  1991.  The difference between acute and chronic pain.  Mt Sinai J Med 58(3):217-220.  

Griep, E. N.,  J. W. Boersma, E. G. Lentjes, A. P. Prins, J. K. van der Korst and E. R. de Kloet. 1998. Function of the hypothalamic-pituitary-adrenal axis in patients with fibromyalgia and low back pain.  J. Rheumatol 25(7):1374-81.

Griep, E. N. , J. W. Boersma, and E. R. de Kloet. 1993. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromylgia syndrome. J Rheumatol 20(3):469-74.

Grieve R, Barnett S, Coghill N et al. 2013. Myofascial trigger point therapy for triceps surae dysfunction: A case series. Man Ther. [June 4 Epub ahead of print]. Four women and 6 men with triceps surae dysfunction ("triceps surae" is an anatomical term for the combination of gastrocnemius and soleus muscles) were evaluated for myofascial trigger points. All participants had active and latent myofascial TrPs on assessment. A program of trigger point pressure release, self-TrP release and home stretching was instituted. Ankle dorsiflexion, pain scale, function scale improve, and improvement was still evident 6 weeks later. "This case series suggests that a brief course of multimodal MTrP therapy would be helpful for some patients with sub-acute or chronic calf pain."

Grieve R, Cranston A, Henderson A et al. 2013. The immediate effect of triceps surae myofascial trigger point therapy on restricted active ankle joint dorsiflexion in recreational runners: A crossover randomized controlled trial. J Bodyw Mov Ther. 17(4):453-461. "To investigate the immediate effect on restricted active ankle joint dorsiflexion range of motion (ROM), after a single intervention of myofascial trigger point (MTrP) therapy on latent triceps surae MTrPs in recreational runners"….a crossover randomized controlled trial was conducted on: "Twenty-two recreational runners (11 men and 11 women…with a restricted active ankle joint dorsiflexion and presence of latent MTrPs….Participants were screened for a restriction in active ankle dorsiflexion in either knee flexion (soleus) or knee extension (gastrocnemius) and the presence of latent MTrPs. Participants were randomly allocated a week apart to both the intervention (combined pressure release and 10 s passive stretch) and the control condition….A clinically meaningful and statistically significant increase in ankle ROM in the intervention compared to the control group was achieved, for the soleus…and the gastrocnemius…."

Grisart, J., Van der Linden M., Masquelier E. 2002. Controlled processes and automaticity in memory functioning in fibromyalgia patients: relation with emotional distress and hypervigilance. J Clin Exp Neuropsychol 24(8):994-1009.  “...memory functioning in fibromyalgia patients is related to their painful condition as a whole rather than to any particular patient’s characteristics.”

Grisart, J. M. and L. H. Plaghki.  1999.  Impaired selective attention in chronic pain patients.Eur J Pain 3(4):325-333.

Grobli C, Dejung B. 2003. [Non-medical therapy of myofascial pain] Schmertz 17(6):475-480. Specific manual therapy is effective for low back trigger point pain.  Connective tissue adhesions that may form in the regions of TrPs as a result of localized edema may be key areas involved in myofascial pain.  They deserve prompt and thorough attention. [German]

Grobli C, Dejung B. 2003. [No Title Given] Schmertz 17(6):475-480. Specific manual therapy is effective for low back trigger point pain. [German]

Groef, Van Kampen M, Dieltjens E et al. 2017. Identification of myofascial trigger points in breast cancer survivors with upper limb pain: Interrater reliability. Pain Med. [Nov 22 Epub ahead of print] "For most muscles, moderate interrater reliability for the identification of MTPs by palpation in breast cancer survivors with upper limb pain was found. Therefore, we concluded that the identification of MTPs by palpation may add to the diagnosis of the myofascial pain syndrome in breast cancer survivors."

Grosman-Rimon L, Clarke H, Mills PB et al. 2016. Clinicians' perspective of the current diagnostic criteria for myofascial pain syndrome. J Back Musculoskelet Rehabil. [Nov 11 Epub ahead of print.] "Myofascial pain syndrome (MPS) is one of the most common chronic musculoskeletal pain disorders. However, MPS is often under-diagnosed. The purpose of this study was to characterize practicing clinicians' perspectives of the current diagnostic criteria for MPS…. The sample population (n= 119) consisted of 40% family physicians, 31% physical medicine (PM) and rehabilitation specialists, 11% rheumatologists, 10% emergency room (ER) physicians, and 8% anesthesiologists specializing in chronic pain…. Our findings demonstrated that participating clinicians agree that "point tenderness" and "pain reproduction" are criteria for MPS. In contrast, the clinicians do not consider "autonomic symptoms" as an important criterion for MPS. The anesthesiologists view "restricted range of motion" as a criterion for MPS more than the other groups and they tend to consider "referred pain" and "pain reproduction" as criteria. Physical medicine and rehabilitation specialists and anesthesiologists tend to view "local twitch response" as a criterion for MPS compared with the other groups. Most groups of clinicians consider "weakness without atrophy" as an important MPS criterion except for family physicians. It is important to note that "poor sleep", "daytime fatigue" and "cognitive symptoms", which are not considered as MPS symptoms, are often mistaken for MPS among practicing clinicians…. Our findings suggest that the diagnostic criteria are not well known, highlighting the need for an expert consensus to determine the importance of each criterion for MPS diagnosis.

Grosshandler SL, Stratas NE, Toomey TC et al. 1985.  Chronic neck and shoulder pain.  Focusing on myofascial origins.  Postgrad Med. 77(3):149-151.  “Chronic neck and shoulder pain is a complex, multifactorial problem.  Often many months have passed since its onset.  During this time the patient may have seen many physicians and tried many medications, some with abuse potential.  Most patients are depressed and have lost their ability to cope with the stresses of daily life.  The goals of therapy are to enable patients to deal with the problem and to bring them to the point where pain is no longer the dominant factor in their lives.  For patients with chronic neck and shoulder pain of myofascial origin, this is accomplished with a multi-disciplinary approach that incorporates use of psychotherapeutic techniques, nonsteroidal anti-inflammatory medications, antidepressant drugs, trigger-point injection, and several physical therapy modalities.”

Grossman P, Tiefenthaler-Gilmer U, Raysz A et al. 2007.  Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up benefits in well-being.  Psychother Psychosom. 76(4):226-233.  “…results indicate mindfulness intervention to be of potential long-term benefit for female fibromyalgia patients.”  

Grotenhermen F. 2005. Cannabinoids. Curr Drug Targets CNS Neurol Disord. 4(5):507-530.  “Cannabinoid receptors are distributed in the central nervous system and many peripheral tissues, including immune system, reproductive and gastrointestinal tracts, sympathetic ganglia, endocrine glands, arteries, lung and heart.”  “The current main focus of clinical research is their efficacy in chronic pain and neurological disorders.”

Gruneberg C, Bloem BR, Honegger F et al.  2004.  The influence of artificially increased hip and trunk stiffness on balance control in man.  Exp Brain Res.  [Epub May 12  ahead of print].  Trunk and hip stiffness increases the possibility of falling. This has implications for people with restricted range of motion due to myofascial TrPs.

Guan H, Koceja DM. 2011. Effects of long-term tai chi practice on balance and h-reflex characteristics. Am J Chin Med. 39(2):251-260. "The findings of this study support the positive effects of Tai Chi exercise on balance control under different conditions."

Guerineau M, Labat JJ, Sibert L et al. 2010. [Treatment of the musculoskeletal component of chronic pelvic and perineal pain]. Prog Urol. 20(12):1103-1110. [French] "The management of patients with chronic pelvic and perineal pain requires preliminary clinical analysis designed to identify trigger points responsible for myofascial pain, pelvic floor muscle tension, and lumbar-pelvic-hip instability. Physiotherapy must be initiated early in the course of the disease by therapists trained in these recent techniques. Botulinum toxin injections have been shown to be effective in piriformis syndrome, but a review of the literature indicates more controversial results in the other chronic pelvic and perineal pain syndromes." [This paper was based on a review of the literature, which reflects the general lack of understanding and knowledge of myofascial TrPs, their ubiquity and their clinical significance. Faulty research begets faulty research. DJS]

Guerrero-Romero F., Rodriguez-Moran M. 2002.  Low serum magnesium levels and metabolic syndrome.  Acta Diabetol 39(4):209-13.  “This study reveals a strong relationship between decreased serum magnesium and MS.”

Guilleminault C, Huang YS, Kirisoglu C et al. 2005.  Is obstructive sleep apnea syndrome a neurological disorder?  A continuous positive airway pressure follow-up study.  Ann Neurol. 58(6):880-887.  “Obstructive sleep apnea syndrome involves abnormal upper airway sensory input, which may be responsible for the development of apneas and hypopneas.  These neurological lesions are persistent despite nasal CPAP treatment.”  Even with relatively successful CPAP treatment for obstructive sleep apnea, heightened pharyngeal sensation persists.

Guilleminault C, Kirisoglu C, Poyares D et al. 2006.  Upper airway resistance syndrome: a long-term outcome study.  J Psychiatr Res. 40(3):273-279.   “Many UARS patients remained untreated following initial evaluation. Worsening of symptoms of insomnia, fatigue and depressive mood were seen with absence of treatment of UARS.”  Sleep studies must include evaluation for UARS, and patients diagnosed with UARS must be treated successfully.  CPAP therapy often is the most efficient treatment.

Gulec H, Sayar K, Yazici Gulec M. 2007.  [The relationship between psychological factors and health care-seeking behavior in fibromyalgia patients]  Turk Psikiyatri Derg. 18(1):22-30 [Turkish].  “The rate of psychiatric and medical history is not related to the FMS syndrome.  Expectations and a normalizing attribution style may contribute to help-seeking behavior for FMS.

Gullacksen AC, Lidbeck J. 2004.  The life adjustment process in chronic pain: psychosocial assessment and clinical implications.  Pain Res. Manag. 9(3):145-153.

Gunter, H. H., H. J. Balks, U. Messner, M. Meffert, U. Nitsche, N. F. Rath and F. Degenhardt. 1999. [No title available. German].  Zentralbl Gynakol 121(8):357-66.

Gupta A, Scott K, Dukewich M. 2017. Innovative technology using virtual reality in the treatment of pain: Does it reduce pain via distraction, or is there more to it? Pain Med. [Aug 31 Epub ahead of print] "These results demonstrate that in addition to distraction, there are novel mechanisms for VR treatment in pain, such as producing neurophysiologic changes related to conditioning and exposure therapies. If these new mechanisms can lead to new treatment options for patients with chronic pain, VR may have the ability to help reduce opioid use and misuse among chronic pain patients. More studies are needed to reproduce results from prospective/pilot studies in large randomized control studies."

Gupta P, Ehlert M, Sirls LT et al. 2016. Transvaginal pelvic floor muscle injection technique: A cadaver study. Female Pelvic Med Reconstr Surg. [Nov 28 Epub ahead of print.] "This is the first study to characterize the distribution of pelvic floor muscle injections in a cadaver model and confirms the ability to deliver medications effectively to the pelvic floor muscles."

Gurkov R, Pyyko I, Zou J et al. 2016. What is Menière's disease? A contemporary re-evaluation of endolymphatic hydrops. J Neurol. 263 Suppl 1:71-81. "Menière's disease is a chronic condition with a prevalence of 200-500 per 100,000 and characterized by episodic attacks of vertigo, fluctuating hearing loss, tinnitus, aural pressure and a progressive loss of audiovestibular functions. … endolymphatic hydrops is responsible not only for the full-blown clinical triad of simultaneous attacks of auditory and vestibular dysfunction, but also for other clinical presentations such as 'vestibular' and 'cochlear Menière's disease'. As a consequence, we propose a new terminology which is based on symptomatic and imaging characteristics of these clinical entities to clarify and simplify their diagnostic classification." Free PMC Article

Gurvich C, Maller JJ, Lithgow B et al. 2013. Vestibular insights into cognition and psychiatry. Brain Res. [Sep 6 Epub ahead of print]. "...emerging research suggests the vestibular system can be considered a potential window for exploring brain function beyond that of maintenance of balance, and into areas of cognitive, affective and psychiatric symptomology. Given the paucity of biological and diagnostic markers in psychiatry, novel avenues to explore brain function in psychiatric disorders are of particular interest and warrant further exploration."

Gusi N, Tomas-Carus P, Hakkinen A et al. 2006.  Exercise in waist-high warm water decreases pain and improves health-related quality of life and strength in the lower extremities in women with fibromyalgia.  Arthritis Rheum. 55(1):66-73.  “The therapy relieved pain and improved HRQOL (health-related quality of life) and muscle strength in the lower limbs at low velocity in patients with initial low muscle strength and high number of tender points.  Most of these improvements were maintained long term.”

Gustaw K. 2000.  Myofascial pain syndrome in farmers – a comprehensive approach to treatment.  Ann Agric Environ Med 7(2):95-99.  “The MPS syndrome was found to be relatively common in Polish farmers and formed 12.7% of all chronic pain syndromes diagnosed in the Institute of Agricultural Medicine during 18 months.”

Guttu RL, Page DG, Laskin DM. 1990.  Delayed healing of muscle after injection of bupivicaine and steroid.  Ann Dent 49(1):5-8.  “Bupivicaine produces more tissue reaction than procaine and that the addition of steroid to bupivicaine increases the initial tissue damage and prolongs the healing phase.”  [Some physicians still use bupivicaine (Marcaine) for TrP injections, although research shows that procaine or lidocaine are much less toxic and more useful for these injections. DJS]

Guven H, Cilliler AE, Comoglu SS. 2012. Cutaneous allodynia in patients with episodic migraine. Neurol Sci. [Nov 23 Epub ahead of print]. "The results of present study revealed that cutaneous allodynia was rather frequent in episodic migraine, particularly in patients having longer disease duration. Higher frequency of allodynia in women and its association with menstrually related migraine may be related to the effects of hormonal factors on cutaneous pain thresholds and central sensitization. Association of nausea and phonophobia with allodynia may be interpreted as the common pathways are shared in the development of these symptoms."

Guymer EK, Clauw DJ.2002  Treatment of fatigue in fibromyalgia.  Rheum Dis Clin North Am 2002 28(2):367-78. "Clearly, fatigue is a large and challenging problem for those suffering from fibromyalgia.  It adds greatly to the morbidity and disability associated with the disease.  In the management of this specific symptom in fibromyalgia, attention should first be focused on identifying comorbidities that may be present and contribute to fatigue.  As with other symptoms of fibromyalgia, education is a critical component of management.  Easier access to well designed nonpharmacologic therapies is essential, because these treatments are underutilized in clinical practice at present."

Guymer EK, Littlejohn GO, Brand CK et al. 2016. Fibromyalgia onset has high impact on work ability in Australians. Intern Med J. [May 31 Epub ahead of print.] "A community pilot survey of Australians with fibromyalgia indicates a high impact on work ability. This occurs from symptom onset and often before diagnosis. Early diagnosis and intervention may provide a window of opportunity to prevent work disability in fibromyalgia."

Habib G, Artul S. 2018. Medical Cannabis for the Treatment of Fibromyalgia. J Clin Rheumatol. [Feb 14 Epub ahead of print] "After commencing MC treatment, all the patients reported a significant improvement in every parameter on the questionnaire, and 13 patients (50%) stopped taking any other medications for fibromyalgia. Eight patients (30%) experienced very mild adverse effects....Medical cannabis treatment had a significant favorable effect on patients with fibromyalgia, with few adverse effects."

Hackshaw KV, Rodriguez-Saona L, Plans M et al. 2013. A bloodspot-based diagnostic test for fibromyalgia syndrome and related disorders. Analyst. [Apr 17 Epub ahead of print]. "The aim of this study was to investigate the ability of a rapid biomarker-based method for diagnosis of fibromyalgia syndrome (FM) using mid-infrared microspectroscopy (IRMS) to differentiate patients with FM from those with osteoarthritis (OA) and rheumatoid arthritis (RA), and to identify molecular species associated with the spectral patterns….Metabolomic analysis revealed that RA and OA groups were metabolically similar, whereas biochemical differences were identified in the FM that were quite distinctive from those found in the other two groups. Both IRMS and metabolomic analysis identified changes in tryptophan catabolism pathway that differentiated patients with FM from those with RA or OA."

Haddad A, Zisman D. 2017. Comorbidities in patients with psoriatic arthritis. Rambam Maimonides Med J. 8(1). "Epidemiological studies have shown that patients with psoriatic arthritis (PsA) are often affected by numerous comorbidities that carry significant morbidity and mortality. Reported comorbidities include diabetes mellitus, obesity, metabolic syndrome, cardiovascular diseases, osteoporosis, inflammatory bowel disease, autoimmune eye disease, non-alcoholic fatty liver disease, depression, and fibromyalgia. All health care providers for patients with PsA should recognize and monitor those comorbidities, as well as understand their effect on patient management to ensure an optimal clinical outcome." Free Article

Hagenfeld D, Schulz T, Ehling P et al. 2010. Depolarization of the membrane potential by hyaluronan. J Cell Biochem. 111(4):858-864. "Depolarization of the plasma membrane by hyaluronan (hyaluronic acid) represents an additional pathway of signal transduction to the classical CD44 signal transduction pathway, which links the extracellular matrix to intracellular metabolism." [This research meshes well with the studies we did on geloid masses inpatients with FM and CMP, and indicates that patients with FM and CMP may need to be very careful using any product with hyaluronic acid. That is a component in many cosmetics, body lotions, and anti-aging formulas. DJS]

Hagglund, K. J., W. E. Deuser, S. P. Buckelew, J. Hewett and D. R. Kay.  1994.  Weather, beliefs about weather, and disease severity among patients with fibromyalgia.  Arthritis Care Res7(3):130-135.

Hajhashemi V, Minaiyan M, Banafshe HR et al. 2015. The anti-inflammatory effects of venlafaxine in the rat model of carrageenan-induced paw edema. Iran J Basic Med Sci. 18(7):654-658. This rodent study from Iran…"demonstrated that venlafaxine has potent anti-inflammatory effect which is related to the peripheral and central effects of this drug. Also we have shown that anti-inflammatory effect of venlafaxine is mediated mostly through the inhibition of IL-1β and TNF-α production and decreases MPO activity in the site of inflammation." Free PMC Article [This is a good reminder that many meds have more than one action. DJS]

Hakim A, De Wandele I, O'Callaghan C et al. 2017. Chronic fatigue in Ehlers-Danlos syndrome-Hypermobile type. Am J Med Genet C Semin Med Genet. 175(1):175-180. "Chronic fatigue is an important contributor to impaired health-related quality of life in Ehlers-Danlos syndrome. There is overlap in the symptoms and findings of EDS and chronic fatigue syndrome. A proportion of those with CFS likely have EDS that has not been identified. The evaluation of chronic fatigue in EDS needs to include a careful clinical examination and laboratory testing to exclude common causes of fatigue including anemia, hypothyroidism, and chronic infection, as well as dysfunction of major physiological or organ systems. Other problems that commonly contribute to fatigue in EDS include sleep disorders, chronic pain, deconditioning, cardiovascular autonomic dysfunction, bowel and bladder dysfunction, psychological issues, and nutritional deficiencies. While there is no specific pharmacological treatment for fatigue, many medications are effective for specific symptoms (such as headache, menstrual dysfunction, or myalgia) and for co-morbid conditions that result in fatigue, including orthostatic intolerance and insomnia. Comprehensive treatment of fatigue needs to also evaluate for biomechanical problems that are common in EDS, and usually involves skilled physical therapy and attention to methods to prevent deconditioning. In addition to managing specific symptoms, treatment of fatigue in EDS also needs to focus on maintaining function and providing social, physical, and nutritional support, as well as providing ongoing medical evaluation of new problems and review of new evidence about proposed treatments."

Hakonarson H, Thornorsson A. 2001.  [Common causes of sleep disturbances in Icelandic children who undergo sleep studies.]  Laeknabladid 87(10):799-804.  [Icelandic]  “…both OSA and GER are common problems in children with sleep disturbances.  We conclude that sleep studies are important in the overall workup of children with sleep disturbances….”

Halder GE, Scott L, Wyman A et al. 2017. Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain. Investig Clin Urol. 58(2):134-139. "Botox combined with soft tissue myofascial release physical therapy under anesthesia can be effective in treating women with chronic pelvic pain secondary to MFPP." Free Article

Haliloglu S, Carlioglu A, Akdeniz D et al. 2014. Fibromyalgia in patients with other rheumatic diseases: prevalence and relationship with disease activity. Rheumatol Int. [Mar 4 Epub ahead of print.] "Concomitant FM is a common clinical problem in rheumatologic diseases, and its recognition is important for the optimal management of these diseases. Increased pain, physical limitations, and fatigue may be interpreted as increased activity of these diseases, and a common treatment option is the prescription of higher doses of biologic agents or corticosteroids. Considerations of the FM component in the management of rheumatologic diseases increase the likelihood of the success of the treatment."

Haliloglu S, Carlioglu A, Sahiner E et al. 2014. Mean platelet volume in patients with fibromyalgia. Z Rheumatol. [Feb 20 Epub ahead of print.] "These results suggest that an early atherosclerosis marker, mean platelet volume, is elevated in patients with fibromyalgia. This indicates increased platelet activation and therefore a higher risk of future cardiovascular disease."

Haliloglu S, Ekinci B, Uzkeser H et al. 2017. Fibromyalgia in patients with thyroid autoimmunity: prevalence and relationship with disease activity. Clin Rheumatol.[Feb 7 Epub ahead of print.] "Fibromyalgia (FM) is a syndrome characterised by chronic musculoskeletal pain, tenderness and other somatic symptoms. The prevalence of FM is approximately 2-7% in the general global population and is 30-40% in the population of Hashimoto thyroiditis (HT) with a structural pathology. In 2010, new classification criteria for FM were proposed as an alternative to the American College of Rheumatology (ACR) 1990 criteria. The objectives of the present study were to identify the prevalence of FM in the HT population and evaluate the associated features by using the new diagnostic criteria. The study group included 79 consecutive patients with HT with or without FM. Recorded data included age, gender, laboratory parameters, sociodemographic features and clinical findings, presence of somatic symptoms, and disease activity indices…. The prevalence of FM in patients with HT was 62%. Antithyroid peroxidase antibody (TPOAb) positivity, duration of disease, and waist circumference were significantly associated with concomitant FM…. A strong positive correlation was noted between fibromyalgia impact questionnaire (FIQ) scores and disease duration, age, values of thyroid-stimulating hormone (TSH) and TPOAb, waist circumference and marital status. TPOAb was found to be independent of body mass index, age and TSH. Concomitant FM is a common clinical problem in HT and its recognition is important for the optimal management of the disease. The new set of diagnostic criteria for FM reinforces this situation. Consideration of the FM component in the management of HT increases the likelihood of treatment success."

Hall AM, Maher CG, Lam P et al. 2011. Tai chi exercise for treatment of pain and disability in people with persistent low back pain: A randomized controlled trial. Arthritis Care Res (Hoboken). 63(11):1576-1583. "Tai chi exercise reduced bothersomeness of back symptoms by 1.7 points on a 0-10 scale, reduced pain intensity by 1.3 points on a 0-10 scale, and improved self-report disability by 2.6 points on the 0-24 Roland-Morris Disability Questionnaire scale."

Hallberg, L. R. and S. G. Carlsson.  1998.  Anxiety and coping in patients with chronic work-related muscular pain and patients with fibromyalgia.  Eur J Pain 2(4):309-319.

Hamada H, Moriwaki K, Shiroyama K et al. 2000. Myofascial pain in patients with postthoracotomy pain syndrome.  Reg Anesth Pain Med. 25(3):302-305.  “Postthoracotomy pain may result, at least in part, from a nonneuropathic origin (myofascial pain).  It is recommended that each patient be examined in detail to determine whether there is a trigger point in a taut muscular band within the scapular region.  If found, this point is suggested as a good area for anesthetic injection.”

Hamnes B, Hauge MI, Kjeken I et al. 2011. 'I have come here to learn how to cope with my illness, not to be cured': A Qualitative Study of Patient Expectations Prior to a One-Week Self-Management Program. Musculoskeletal Care. [Jul 20 Epub ahead of print]. "Self-management programs (SMPs) have been developed to help patients with chronic rheumatic diseases to manage their health problems. Patients' expectations prior to treatment are important determinants of outcomes, and should therefore be identified, to ensure that interventions meet the participants' needs. The aim of the present study was to determine participant expectations with respect to a one-week inpatient SMP for those with fibromyalgia (FM) and rheumatoid arthritis (RA).....The findings show that the participants expected the SMP to be a turning point towards a better future and to empower them to assume more responsibility for their own health and self-care."

Han L, Ma C, Liu Q et al. 2013. A subpopulation of nociceptors specifically linked to itch. Nat Neurosci 16(2):174-182. This team has found a new itch-specific type of neuron in mice. This is a big first step in developing itch-specific therapies that will stop itching that anti-histamines don't help.

Han T, Hong CZ, Kuo FC et al. 2012. Mechanical pain sensitivity of deep tissues in children—possible development of myofascial trigger points in children. BMC Musculskeletal Disord. 13:13. After checking 505 healthy school children, age 4-11 years, signs of developing myofascial trigger points were seen at the age of 4 and up. These included attachment TrPs and latent TrPs. Only sites in the brachioradialis muscle and the lateral epicondyle were checked.

Han SC, Harrison P. 1997.  Myofascial pain syndrome and trigger-point management.  Reg Anesth 22(1):89-101.  “A multidisciplinary approach to treatment appears to be most beneficial and may include such modalities as trigger-point injections, dry needling, stretch and spray, and transcutaneous electrical nerve stimulation.”

Han, S. C. and P. Harrison.  1997.  Myofascial pain syndrome and trigger-point management.Reg Anesth 22(1):89-101.  

Han, Y., J. Wang, D. A. Fischman, H. F. Biller and I. Sanders.  1999.  Slow tonic muscle fibers in the thyroarytenoid muscles of human vocal folds; a possible specialization for speech. Anat Rec 256(2):146-57. 

Hanani M., T. Huang, P. Cherkas et al. 2002. Glial cell plasticity in sensory ganglia induced by nerve damage. Neuroscience 114(2):279. Changes in glial cells may contribute to neuropathic pain.

Handa T, Fukuda K, Ichinohe T. 2013. Effect of Combination of Trigger Point Injection and Stellate Ganglion Block on Non-odontogenic Mandibular Molar Pain Referred from Masseter Muscle: A Case Report. Bull Tokyo Dent Coll. 54(3):171-175. "We report a case of myofascial pain syndrome (MPS), manifested as nonodontogenic mandibular molar pain referred from the masseter muscle, relieved by a combination of trigger point injection (TPI) and stellate ganglion block (SGB). The patient was a 32-year-old woman who had experienced cold hypersensitivity in the right third mandibular molar 2 months prior to visiting our department. Subsequently, she had visited a family dentist and undergone pulpectomy under local anesthesia. She eventually visited our clinic because there was no marked change in her symptoms. On the first visit, no tooth abnormality was found and the patient was neither anxious nor depressive. Tender points were found in the right masseter and temporal muscles during muscle palpation. Referred pain radiating to the right mandibular molars was observed when pressure was applied to the central portion of the right masseter muscle. As a result, we diagnosed MPS based on evidence of nonodontogenic tooth pain caused by referred pain from the masseter muscle. We performed TPI with 2% lidocaine hydrochloride to the tender point in the masseter muscle. Although the visual analog scale (VAS) pain score dropped from 97 to 36, complete pain relief was not achieved. The TPI was effective for approximately 7 hrs, after which severe throbbing pain returned. The sustained nature of the tooth pain suggested that it was sympathetic nerve-dependent. Subsequently, we performed SGB, resulting in a reduction in the VAS pain score from 90 to 32. Therefore, we performed another TPI and the VAS pain score dropped to 0. We continued SGB and TPI for the next 3 days and the symptoms disappeared. Thus, a combination of TPI and SGB controlled MPS manifested as masseter muscle-mediated nonodontogenic tooth pain."

Handberg G. 2017. [Pharmacological treatment of chronic non-cancer pain]. Ugeskr Laeger. 179(26). [Article in Danish] "19% of the grown-up Danish population suffer from a chronic pain condition. Most patients are treated by general practitioners (GPs), and only a smaller group need specialist treatment. This article goes through the pharmacological possibilities available with a special focus on treatment by GPs. For chronic pain as fibromyalgia and low back pain non-steroidal anti-inflammatory drugs and paracetamol are not recommended on a regular basis. The main pharmacological treatment is tricyclic antidepressants and gabapentinoids. If opioids are needed, long acting drugs are preferred."

Handwerker, H. O. , C. Forster and C. Kirchhoff. 1991. Discharge patterns of human C-fibers into used by itching and burning stimuli.  J Neurophysiol 66(1):307-15.

Hannah MC, Cope J, Palermo A et al. 2016. Comparison of two angles of approach for trigger point dry needling of the lumbar multifidus in human donors (cadavers). Man Ther. 26:160-164. "All four inferomedial approach needles ended at the lamina of the vertebrae below. All four posterior-anterior approach needles ended in the lamina of the same level…. All eight needles traversed the lumbar multifidus and ended in the lumbar lamina with little possibility of the needle entering the subarachnoid space. Thus both the inferomedial and the posteroanterior angles of approach are efficacious for clinicians to use in dry needling of the lumbar mulifidus."

Hansraj KK. 2014. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 25:277-279. "Billions of people are using cell phone devices on the planet, essentially in poor posture. The purpose of this study is to assess the forces incrementally seen by the cervical spine as the head is tilted forward, into worsening posture. This data is also necessary for cervical spine surgeons to understand in the reconstruction of the neck." The study from New York Spine Surgery & Rehabilitation Medicine again validated information on the head-forward position as a perpetuating factor for pain and dysfunction. With the head erect in a healthy position, it places a weight of about 10 pounds on your straight spine. This is the weight the spine is designed to hold comfortably. When the head is tilted downward even 2 to 3 inches, it causes the stress on the spine to the equivalent of 27 pounds of weight. The more you tilt your head, such as to look down at a laptop or other device, the greater the weight of stress on your head. The use of electronic devices has developed a medical condition, called "tech neck".

Hansson E, Svensson H, Brorson H. 2012. Review of Dercum's disease and proposal of diagnostic criteria, diagnostic methods, classification and management. Orphanet J Rare Dis. 7(1):23. "We propose the minimal definition of Dercum's disease to be generalized overweight or obesity in combination with painful adipose tissue. The associated symptoms in Dercum's disease include obesity, fatty deposits, easy bruisability, sleep disturbances, impaired memory, depression, difficulty concentrating, anxiety, rapid heartbeat, shortness of breath, diabetes, bloating, constipation, fatigue, weakness and joint and muscle aches….The prevalence of Dercum's disease has not yet been exactly established. Aetiology: Proposed, but unconfirmed aetiologies include: nervous system dysfunction, mechanical pressure on nerves, adipose tissue dysfunction and trauma. Diagnosis and diagnostic methods: Diagnosis is based on clinical criteria and should be made by systematic physical examination and thorough exclusion of differential diagnoses. Advisably, the diagnosis should be made by a physician with a broad experience of patients with painful conditions and knowledge of family medicine, internal medicine or pain management. The diagnosis should only be made when the differential diagnoses have been excluded ….Differential diagnoses include: fibromyalgia, lipoedema, panniculitis, endocrine disorders, primary psychiatric disorders, multiple symmetric lipomatosis, familial multiple lipomatosis, and adipose tissue tumors….The following treatments have lead to some pain reduction in patients with Dercum's disease: Liposuction, analgesics, lidocaine, methotrexate and infliximab, interferon -2b, corticosteroids, calcium-channel modulators and rapid cycling hypobaric pressure. As none of the treatments have led to long lasting complete pain reduction and revolutionary results, we propose that Dercum's disease should be treated in multidisciplinary teams specialized in chronic pain. Prognosis: The pain in Dercum's disease seems to be relatively constant over time." [Dercum's may be mistaken for either FM or CMP, coexisting with insulin resistance. DJS]

Hao J, Ruel J, Coste B et al. 2013. Piezo-electrically driven mechanical stimulation of sensory neurons. Methods Mol Biol. 998:159-170. "Mechanotransduction, the conversion of a mechanical stimulus into a biological response, constitutes the basis of a variety of physiological functions such as the senses of touch, balance, proprioception, blood pressure, and hearing. In vertebrates, mechanosensation is mediated by mechanosensory neurons, whose cell bodies are located in trigeminal and dorsal root ganglia. Here, we describe an in vitro model of mechanotransduction that provides an opportunity to explore the properties of mechanosensitive channels in mammalian sensory neurons. The mechano-clamp method allows applying local force on plasma membrane of whole-cell patch-clamped sensory neurons. This technique uses a mechanical probe driven by a computer-assisted piezoelectric microstage to repeatedly stimulate sensory neurons with accurate control of stimulus strength, duration, and speed." [Considering the piezoelectrical properties of myofascia, this might prove interesting. DJS]

Hapidou, E. G.  and G. B. Rollman. 1998. Menstrual cycle modulation of tender points.  Pain 77(2):151-61

Haq SA, Darmawan J, Islam MN et al. 2005.  Prevalence of rheumatic diseases and associated outcomes in rural and urban communities in Bangladesh: a COPCORD study.  J Rheumatol. 32(2):348-353.  “Fibromyalgia is a common cause of morbidity, disability, and work loss in rural and urban communities of Bangladesh.”  [Fibromyalgia syndrome occurs worldwide, irrespective of race, socioeconomic class, or other variables. DJS]

Harbeck B, Sufke S, Harten P et al. 2013. High prevalence of fibromyalgia-associated symptoms in patients with hypothalamic-pituitary disorders. Clin Exp Rheumatol. [Epub ahead of print.] "Our data suggest that patients with hypothalamic-pituitary disorders may be at increased risk of developing fibromyalgia-associated symptoms."

Hargrove JB, Bennett RM, Clauw DJ. 2012. Long-Term Outcomes in Fibromyalgia Patients Treated with Noninvasive Cortical Electrostimulation. Arch Phys Med Rehabil. [Apr 20 Epub ahead of print]. "Sixty-nine originally studied subjects were eligible, 39 of which were mailed surveys. There was a 64% survey return rate. The total FIQ score was 52.6 at baseline, 35.7 at end-of-study and 31.8 at follow-up….Subjects reported symptom improvements lasting at least two-years, with a reduction or elimination of medicine use and need to see physicians for FM….A high percentage of FM patients treated with RINCE (Reduced Impedance Noninvasive Cortical Electrostimulation) continued to experience worthwhile improvement at follow-up."

Harris RE, Clauw DJ, Scott DJ et al. 2007.  Decreased central mu-opioid receptor availability in fibromyalgia.  J Neurosci. 27(37):10000-10006.  Positron emission tomography indicates that FM patients have a decreased mu-opioid binding potential in several areas of the brain associated with pain modulation.  This altered endogenous opioid activity may explain why it takes a greater amount of opioids for some FM patients to produce the same amount of pain control.

Harris RE, Clauw DJ. 2006.  How do we know fibromyalgia is “real?”  Curr Pain Headache Rep (10):403-407.  There is now “overwhelming data” that indicate FMS is real, with genetic predisposition.  Functional magnetic resonance imaging (fMRI) and single photon emission computed tomography (SPECT) show significant difference between FMS patients and others.  It is not a psychological, functional or “somatic” disorder.  A variation in the gene that encodes the enzyme catechol-O-methyl transferase, significantly affects pain sensitivity and pain-related emotions and feelings.  This enzyme also is related to development of TMJD.  The pain is real, and it can be shown by radiological studies. 

Harrison, D. E., R. Cailliet, D. D. Harrison, S. J. Troyanovich and S. O. Harrison.  1999. A review of biomechanics of the central nervous system–Part I: spinal canal deformations resulting from changes in posture.  J Manipulative Physiol Ther 22(4):227-34.

Hart FX. 2009.  Cytoskeletal forces produced by extremely low-frequency electric fields acting on extracellular glycoproteins.  [Jul 10 Epub ahead of print].  This article may explain one of the mechanisms by which microcurrent and other electroceutical devices can create changes in the cellular matrix.

Hart, P., S. Townley, M. Grimbaldston et al. 2002. Mast cells, neuropeptides, histamine, and prostagladins in UV-induced systemic immunosuppression. Methods 28(1):79.  This article points out the direct correlation between dermal mast cell prevalence and susceptibility to UVB-induced systemic immunosuppression in mice. [Above normal counts of mast cells have been found in fibromyalgia patients.] The authors propose histamine and prostaglandin E2 are important in downstream immunosuppression.

Harte SE, Ichesco E, Hampson JP et al. 2016. Pharmacologic attenuation of cross-modal sensory augmentation within the chronic pain insula. Pain. [Apr 19 Epub ahead of print.] "Centralized chronic pain conditions such as fibromyalgia are often associated with symptoms of multisensory hypersensitivity. In the present study, female fibromyalgia patients demonstrated cross-modal hypersensitivity to visual and pressure stimuli compared to age- and sex-matched healthy controls. Functional magnetic resonance imaging (fMRI) revealed that insular activity evoked by an aversive level of visual stimulation was associated with the intensity of fibromyalgia pain. Moreover, attenuation of this insular activity by the analgesic pregabalin was accompanied by concomitant reductions in clinical pain….These data suggest that abnormal integration of multisensory and pain pathways within the insula may represent a pathophysiological mechanism in some chronic pain conditions, and that insular response to aversive visual stimulation may have utility as a marker for analgesic drug development."

Hartmann D, Sarton J. 2014. Chronic pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. [Jul 17 Epub ahead of print.] "The successful treatment of women with vestibulodynia and its associated chronic pelvic floor dysfunctions requires interventions that address a broad field of possible pain contributors. Pelvic floor muscle hypertonicity was implicated in the mid-1990s as a trigger of major chronic vulvar pain. Painful bladder syndrome, irritable bowel syndrome, fibromyalgia, and temporomandibular jaw disorder are known common comorbidities that can cause a host of associated muscular, visceral, bony, and fascial dysfunctions. It appears that normalizing all of those disorders plays a pivotal role in reducing complaints of chronic vulvar pain and sexual dysfunction. Though the studies have yet to prove a specific protocol, physical therapists trained in pelvic dysfunction are reporting success with restoring tissue normalcy and reducing vulvar and sexual pain. A review of pelvic anatomy and common findings are presented along with suggested physical therapy management."

Harty J, Soffe K, O'Toole G et al. 2005.  The role of hamstring tightness in plantar fasciitis.  Foot Ankle Int. 26(12):1089-1092.  [Hamstring tightness, such as that due to myofascial TrPs, could be a major unrecognized factor contributing to plantar fasciitis. DJS]

Harvey, A. G. and R. A. Bryant.  1999.  Predictors of acute stress following motor vehicle accidents.  J Trauma Stress 12(3):519-25.

Hashemirad F, Karimi N, Keshavarz R. 2016. The effect of Kinesio taping technique on trigger points of the piriformis muscle. J Bodyw Mov Ther. 20(4):807-814. "Our findings suggest that KT application may be effective for pain relief and increasing ROM (range of motion) in patients with myofascial trigger points in the piriformis muscle."

Hashkes PJ, Friedland O, Jaber L et al. 2004.  Decreased pain threshold in children with growing pains.  J Rheumatol 31(3):610-613.  Growing pain may be indicative of developing fibromyalgia tender points, according to this research, but they did not check for co-existing myofascial TrPs.  Growing pains are often due to TrPs.  Research that takes them into account would be more valuable, because we can't know if the link between the tender points and the growing pains is coincidental.

Hassett AL, Clauw DJ, Williams DA. 2015. Premature aging in fibromyalgia. Curr Aging Sci. [Jul 27 Epub ahead of print.] "Chronic pain is highly prevalent in older adults, and until recently, was considered to be common but relatively 'benign.' Mounting evidence, however, suggests that some of the 116 million US adults who suffer from chronic pain are also at an increased risk for developing age-related diseases prematurely, suffering earlier cognitive and physical decline, and experiencing earlier mortality….Herein, we focus on one chronic pain state, fibromyalgia, and provide an overview of the evidence suggesting that individuals with this chronic pain condition show signs of premature aging."

Hassett AL, Epel E, Clauw DJ et al. 2012. Pain is associated with short leukocyte telomere length in women with fibromyalgia. J Pain. 13(10):959-969. "Telomere length, considered a measure of biological aging, is linked to morbidity and mortality. Psychosocial factors associated with shortened telomeres are also common in chronic pain; yet, little is known about telomere length in pain populations. Leukocyte telomere length was evaluated in 66 women with fibromyalgia and 22 healthy female controls....Our findings support a link between premature cellular aging and chronic pain. These preliminary data imply that chronic pain is a more serious condition than has typically been recognized in terms of bodily aging."

Hassett AL, Radvanski DC, Vaschillo EG et al. 2007.  A pilot study of the efficacy of heart rate variability (HRV) biofeedback in patients with fibromyalgia.  Appl Psychophysiol Biofeedback. [Jan 12 Epub ahead of print]  “These data suggest that HRV biofeedback may be a useful treatment for FM, perhaps mediated by autonomic changes.  While HRV effects were immediate, blood pressure, baroreflex, and therapeutic effects were delayed.  This is consistent with data on the relationship among stress, HPA axis activity, and brain function.”

Hasuo H, Ishihara T, Kanbara K et al. 2016. Myofacial trigger points in advanced cancer patients. Indian J Palliat Care. 22(1):80-84. "Myofascial pain syndrome is starting to be recognized as one of important factors of pain in cancer patients. However, no reports on features of myofascial trigger points were found in terminally-ill cancer populations. This time, we encountered 5 patients with myofascial pain syndrome and terminal cancer in whom delirium developed due to increased doses of opioid without a diagnosis of myofascial pain syndrome on initial presentation. The delirium subsided with dose reductions of opioid and treatment of myofascial pain syndrome. The common reason for a delayed diagnosis among the patients included an incomplete palpation of the painful sites, which led to unsuccessful myofascial trigger points identification.…We consider that careful palpation of the painful site is important, in order to obtain greater knowledge and understanding of the features of myofascial trigger points." Free PMC Article

Hasuo H, Kanbara K, Abe T et al. 2017. Factors associated with the efficacy of trigger point injection in advanced cancer patients. J Palliat Med. 20(10):1085-1090. "The TPI efficacy is likely high when advanced cancer patients have fewer MTrPs together with cancer pain at areas other than the lower back or hip. MTrPs in advanced cancer patients are more commonly observed together with cancer pain rather than independently. Healthcare providers should recognize the relationship between MTrP and cancer pain and proactively perform physical examinations to detect MTrPs for potential TPI."

Hauser RA, Lackner JB, Steilen-Matias D et al. 2016. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clin Med Insights Arthritis Musculoskelet Disord. 9:139-159. "Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature." Free PMC Article

Hauser W, Perrot S, Sommer C et al. 2017. Diagnostic confounders of chronic widespread pain: not always fibromyalgia. Pain Rep. 2(3):e598. "Conditions that may mimic FM may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related.... Although the most likely reason for a complaint of CWP is FM, this pain complaint can be a harbinger of illness other than FM, prompting consideration of a differential diagnosis. This review should sensitize physicians to a broad spectrum of conditions that can mimic FM." [It is important to diagnose co-existing conditions and contributors to the central sensitization state of FM. Fibromyalgia is not an illness of exclusion. The causes of FM central sensitization must be found, and there may be multiple coexisting conditions. Differential diagnosis is not optimum in chronic pain conditions, but rather the process of interactive diagnoses should be employed to discover all conditions that are contributing to patient symptoms. DJS]

Hautanen, A., K. Raikkonen and H. Adlercreutz. 1997. Associations between pituitary-adrenocortical function and abdominal obesity, hyperinsulinaemia and dyslipidaemia in normotensive males.  J Intern Med 241(6):451-61.

Havas M. 2006. Electromagnetic hypersensitivity: biological effects of dirty electricity with emphasis on diabetes and multiple sclerosis. Electromagn Biol Med. 25(4):259-268. "Dirty electricity is a ubiquitous pollutant. It flows along wires and radiates from them and involves both extremely low frequency electromagnetic fields and radio frequency radiation. Until recently, dirty electricity has been largely ignored by the scientific community. Recent inventions of metering and filter equipment provide scientists with the tools to measure and reduce dirty electricity on electrical wires. Several case studies and anecdotal reports are presented. Graham/Stetzer (GS) filters have been installed in schools with sick building syndrome and both staff and students reported improved health and more energy. The number of students needing inhalers for asthma was reduced in one school and student behavior associated with ADD/ADHD improved in another school. Blood sugar levels for some diabetics respond to the amount of dirty electricity in their environment. Type 1 diabetics require less insulin and Type 2 diabetics have lower blood sugar levels in an electromagnetically clean environment. Individuals diagnosed with multiple sclerosis have better balance and fewer tremors. Those requiring a cane walked unassisted within a few days to weeks after GS filters were installed in their home. Several disorders, including asthma, ADD/ADHD, diabetes, multiple sclerosis, chronic fatigue, fibromyalgia, are increasing at an alarming rate, as is electromagnetic pollution in the form of dirty electricity, ground current, and radio frequency radiation from wireless devices. The connection between electromagnetic pollution and these disorders needs to be investigated and the percentage of people sensitive to this form of energy needs to be determined."

Hawk C, Long CR, Rowell RM et al. 2005.  A randomized trial investigating a chiropractic manual placebo: a novel design using standardized forces in the delivery of active and control treatments.  J Altern Complement Med. 11(1):109-117.  “Patients in the control group were not successfully blinded; however, patients’ perceptions of treatment group assignment did not significantly affect outcomes.   The clinically significant improvement in both groups, independent of patient or clinician expectations, suggests the presence of therapeutic factors common to both groups, other than biomechanical force.  Further studies examining other aspects of the clinical encounter, considered separately from biomechanical force, are warranted before arbitrarily designating any intervention as a ‘placebo’.”

Hawkins JL, Denson JE, Miley DR et al. 2015. Nicotine stimulates expression of proteins implicated in peripheral and central sensitization. Neuroscience. [Jan 28 Epub ahead of print.] "Our findings demonstrate that prolonged systemic administration of nicotine promotes sustained behavioral and cellular changes in the expression of key proteins in the spinal trigeminal nucleus and trigeminal ganglion implicated in the development and maintenance of peripheral and central sensitization."

Hayashi K, Ozaki N, Kawakita K et al. 2011. Involvement of NGF in the rat model of persistent muscle pain associated with taut band. J Pain. 12(10):1059-1068. In rats, the taut band associated with myofascial TrPs can be affected by the administration of nerve growth factor (NGF). Mice that received the NGF receptor (TrkA) inhibitor K252a had significantly decreased hyperalgesia related to taut bands. "...NGF expressed in regenerating muscle cells is involved in persistent muscular mechanical hyperalgesia. NGF-TrkA signaling in primary muscle afferent neurons may be one of the most important and promising targets for MPS."

Hayden RJ, Louis DS, Doro C. 2005.  Fibromyalgia and myofascial pain syndromes and the workers’ compensation environment: an update.  Clin Occup Environ Med. 5(2):455-469.  “Controversy exists as to whether fibromyalgia and myofascial pain syndromes represent a specific pathology or are merely terms to describe clinical conditions that provide patients with the reassurance that their symptoms are real and help clinicians with therapeutic direction.  In the occupational health setting, this uncertainty can lead to significant difficulty in determining short- and long-term disability and assigning culpability to an individual’s work environment.”

Hayes SM, Myhal GC, Thornton JF et al. 2010. Fibromyalgia and the therapeutic relationship: where uncertainty meets attitude. Pain Res Manag. 15(6):385-391. "GPs reported insufficient knowledge and skill in diagnosing fibromyalgia, with not all believing it to be a diagnosable condition…. Twenty-three per cent of GPs and 12% of specialists characterized fibromyalgia patients as malingerers. They further reported a lack of knowledge and skill in treating fibromyalgia…., including the pain, sleep disorders and mood disorders related to the condition…. Specialists shared these challenges, although to a lesser degree ….. Attitudinal issues centered around frustration….and negative profiling of fibromyalgia patients….Findings revealed the presence of GP attitudinal and confidence challenges in caring for fibromyalgia patients. As care of fibromyalgia patients moves to general practices, these fundamental competencies must be addressed to assure that all patients receive the quality of care necessary to manage their disease and to empower physicians to be more professionally effective. As stated by one patient, 'why are we being penalized for having this disability?'" [As the information on central sensitization mounts, it is sad to see so much evidence that so few care providers in the trenches are reading it and understanding what they read. Patients do get penalized for the ignorance of their care providers, and thus the care providers are doing them harm, failing to providing care because they do not understand fibromyalgia (and other central sensitization states), or myofascial trigger points, two of the three most common causes of musculoskeletal pain. DJS]

Haythornthwaite, J. A., L. A. Menefee, A. L. Quatrano-Piacentini and M. Pappagallo.  1998. Outcome of chronic opioid therapy for non-cancer pain.  J Pain Symptom Manage 15(3):185-94.

He C, Ma H. 2017. Effectiveness of trigger point dry needling for plantar heel pain: a meta-analysis of seven randomized controlled trials. J Pain Res. 10:1933-1942. "MTrP (myofascial trigger point) needling effectively reduced the heel pain due to plantar fasciitis. However, considering the potential limitations in this study, more large-scale, adequately powered, good-quality placebo-controlled trials are needed to provide more trustworthy evidence in this area."

He D, Veiersted KB, Hostmark AT et al. 2004.  Effect of acupuncture treatment on chronic neck and shoulder pain in sedentary female workers: a 6-month and 3-year follow-up study.  Pain 109(3):299-307.  “Adequate acupuncture treatment may reduce chronic pain in the neck and shoulders and related headache.  The effect lasted for 3 years.”

Healy GM, Finn DP, O'Gorman D et al. 2015. Pretreatment anxiety and pain acceptance are associated with response to trigger point injection therapy for chronic myofascial pain. Pain Med. Aug 26. [Epub ahead of print] This study from the National University of Ireland found that trigger point injection results for chronic myofascial pain if the paraspinal muscles could be influenced negatively by psychological factors, especially pre-treatment anxiety. [This confirms work by Janet G. Travell that found that trigger point injection had less of a chance of success if the muscles were not relaxed. DJS]

Heath KM, Elovic EP. 2006.  Vitamin D deficiency: implications in the rehabilitation setting.  Am J Phys Med Rehabil. 85(11):916-923.  “Vitamin D deficiency should be included in the differential diagnosis in the evaluation of musculoskeletal pain complaints in the rehabilitation setting, and treatment of any identified deficiency should be considered a potentially important component of the treatment regimen.”

Hellou R, Hauser W, Brenner I, Buskila D et al. 2017. Self-reported childhood maltreatment and traumatic events among Israeli patients suffering from fibromyalgia and rheumatoid arthritis. Pain Res Manag. [Jan 11 Epub ahead of print.] "The study demonstrated the cross cultural association between FMS and childhood maltreatment, including neglect, emotional abuse, and PTSD. Significant differences were demonstrated between FMS patients and patients suffering from RA, a model of an inflammatory chronic rheumatic disease." Free Article

Hendler, N. 1984. Depression caused by chronic pain. J Clin Psychiatry 45(3 pt 2):30-38.

Henrich CF, Ramulu PY, Akpek EK. 2014. Association of dry eye and inflammatory systemic diseases in a tertiary care-based sample. Cornea. 33(8):819-825."Systemic inflammatory diseases are frequently associated with dry eye in patients evaluated at a tertiary academic center. Diagnostic evaluations may help uncover previously undiagnosed significant conditions in about one-third of tested patients."

Henriksson CM, Liedberg GM, Gerdle B. 2005.  Women with fibromyalgia: work and rehabilitation.  Disabil Rehabil. 27(12):685-694.  “The total life situation, other commitments, type of work tasks, the ability to influence the work situation, and the physical and psychosocial work environment are important factors in determining whether a person can remain in a work role.  More knowledge is needed about how to adjust work conditions for people with partial work ability to the benefit of society and the individual.”

Henriksson CM. 1995.  Living with continuous muscular pain — patient perspectives.  Part I: Encounters and consequences.  Scand J Caring Sci 9(2):67-76.  “The contradiction between the patients’ perception of illness and the lack of objective findings is stressful.  The women feel rejected, misunderstood, and disbelieved, which prevents them from dealing with their situation constructively.  Long investigation periods provoke anxiety, and confirmation of the diagnosis is a relief.  Daily routines are disrupted, conflicts between life roles lead to additional stress and the women experience loss of ability to perform valued activities, lack of physical fitness and loss of future opportunities.  Patients need early and adequate information and the consequences of the condition must be acknowledged and taken into consideration if secondary economic and psychosocial consequences are to be minimized.”

Henriksson KG. 2009.  The fibromyalgia syndrome: translating science into clinical practice.  J Musculoskel Pain. 17(2):189-194.  “The biological part of FMS reflects a long-standing or permanent change in the function of the nociceptive nervous system that can be equated with a disease.  It is hoped that upgrading FMS from illness to disease will increase the awareness of FMS among health personnel.  This will in turn help patients with FMS to get correct diagnosis and treatment.”

Henriksson M, Henriksson J, Bergenius J. 2011. Gait initiation characteristics in elderly patients with unilateral vestibular impairment. Gait Posture. [Mar 28 Epub ahead of print]. "....chronically impaired vestibular function leads to a different strategy to create forward momentum to the body. In addition, there is evidence that vestibular patients have diminished postural stability, or alternatively a more cautious behavior, when initiating the second step."

Henriques DY, Cressman EK. 2012. Visuomotor adaptation and proprioceptive recalibration. J Mot Behav. 44(6):435-444. "Motor learning, in particular motor adaptation, is driven by information from multiple senses. For example, when arm control is faulty, vision, touch, and proprioception can all report on the arm's movements and help guide the adjustments necessary for correcting motor error. In recent years we have learned a lot about how the brain integrates information from multiple senses for the purpose of perception. However, less is known about how multisensory data guide motor learning. Most models of, and studies on, motor learning focus almost exclusively on the ensuing changes in motor performance without exploring the implications on sensory plasticity. Nor do they consider how discrepancies in sensory information (e.g., vision and proprioception) related to hand position may affect motor learning. Here, we discuss research from our lab and others that shows how motor learning paradigms affect proprioceptive estimates of hand position, and how even the mere discrepancy between visual and proprioceptive feedback can affect learning and plasticity. Our results suggest that sensorimotor learning mechanisms do not exclusively rely on motor plasticity and motor memory, and that sensory plasticity, in particular proprioceptive recalibration, plays a unique and important role in motor learning." [This is of importance, since most trigger points, and probably fibromyalgia, have proprioceptive components. DJS]

Henry L. 2015. Chiropractic management of postpartum pubic symphysis diastasis: A case report. J Can Chiropr Assoc. 59(1):30-36. "This case report describes the chiropractic management of a 30-year-old female patient with severe postpartum pelvic pain secondary to pubic symphysis diastasis. No literature was found on the chiropractic management of postpartum symphysis pubis diastasis. The existing literature concerning chiropractic care for symphysis pubis dysfunction during pregnancy is limited and indicates a potential benefit. Separation of the pubic symphysis may include ligamentous injury to the sacroiliac joints and may lead to chronic pain. Pubic symphysis separation of 17 millimeters was present on digital radiograph. Management consisted of chiropractic adjustments, trigger point release, electrical stimulation, moist heat, sacroiliac belt, and specific stabilizing exercises. The patient's pain improved immediately following treatment on the initial visit. Pain was reduced from 8/10 VAS at the first visit to 2/10 at the fourth visit. She was able to resume normal activities and reached a final pain level of 1/10. The diastasis was reduced by 7 millimeters at 14-weeks post radiograph for a final separation of just under 10 millimeters. Collaboration between obstetricians, midwives and chiropractors may be warranted." Free PMC Article

Henry R, Cahill CM, Wood g et al. 2012. Myofascial pain in patients waitlisted for total knee arthroplasty. Pain Res Manag 17(5):321-327. "Knee pain is one of the major sources of pain and disability in developed countries, particularly in aging populations, and is the primary indication for total knee arthroplasty (TKA) in patients with osteoarthritis (OA)....Following ethics approval, 25 participants were recruited from the wait list for elective unilateral primary TKA at the study centre. After providing informed consent, all participants were examined for the presence of active trigger points in the muscles surrounding the knee and received trigger point injections of bupivacaine. Assessments and trigger point injections were implemented on the first visit and at subsequent visits on weeks 1, 2, 4 and 8 ...Myofascial trigger points were identified in all participants. Trigger point injections significantly reduced pain intensity and pain interference, and improved mobility...All patients had trigger points in the vastus and gastrocnemius muscles, and 92% of patients experienced significant pain relief with trigger point injections at the first visit, indicating that a significant proportion of the OA knee pain was myofascial in origin. Further investigation is warranted to determine the prevalence of myofascial pain and whether treatment delays or prevents TKA."

Herald, J. and M.Pecenka. 1991.  Pain doctors: the real world of a pain practice.  An interview with Lawrence A. Funt. Dental Management March, 26-29.  

Heredia-Jimenez J, Orantes-Gonzalez E. 2018. Gender differences in patients with fibromyalgia: a gait analysis. Clin Rheumatol. [Sep 21 Epub ahead of print] "This study analysed the spatio-temporal parameters, asymmetry, variability and bilateral coordination of gait in women and men with fibromyalgia and healthy subjects walking at their usual velocity and at a faster walking velocity.... The fibromyalgia groups showed increased bilateral coordination, asymmetry and variability of stance phase when walking fast. The fibromyalgia women showed significant spatio-temporal, variability and bilateral coordination of gait differences compared with the healthy women. The fibromyalgia men reported significant differences in velocity, cadence, stride length, swing time variability and stance gait asymmetry indices compared with the healthy men. No significant differences were observed between the men and women in the fibromyalgia groups. The findings of the present study did not support gender-specific differences in walking variables and indices in FM patients. The differences found between both genders of FM patients and healthy subjects in walking indices at fast velocities could be a useful tool for diagnoses and evaluation of male and female patients with FM during short-term fast walking tests. [Future studies by this team will include assessment of relevant myofascial trigger points. DJS]

Hermans L, Nijs J, Calders P et al. 2017. Influence of morphine and naloxone on pain modulation in Rheumatoid Arthritis, Chronic Fatigue Syndrome/Fibromyalgia and controls: a double blind randomized placebo-controlled cross-over study. Pain Pract. [Jul 19 Epub ahead of print] "This study revealed anti-hyperalgesia effects of morphine in CFS/FM and RA patients. Nevertheless, these effects were comparable to placebo. Besides, neither morphine nor naloxone influenced Deep Tissue Pain, temporal summation or CPM. Therefore, these results suggest that the opioid system is not dominant in (enhanced) bottom-up sensitization (temporal summation) or (impaired) endogenous pain inhibition (CPM) in patients with CFS/FM or RA in chronic pain patients.

Hernanz F, Fidalgo M, Munoz P et al. 2016. Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. 69(8):e168-173. Even though reduction mammoplasty has been shown of benefit to the health of patients in pain, obese women are often refused this relief. This study showed that obese women who had symptoms due to over-large breasts obtained increased quality of life and pain reduction which was sustained over time.

Herregods TV, Bredenoord AJ, Smout AJ. 2015. Pathophysiology of gastroesophageal reflux disease: new understanding in a new era. Neurogastroenterol Motil. [Jun 5 Epub ahead of print.] "The prevalence of gastroesophageal reflux disease (GERD) has increased in the last decades and it is now one of the most common chronic diseases….the pathophysiology of GERD…is now recognized to be a multifactorial disease. Among the factors that have been shown to be involved in the provocation or increase of reflux, are sliding hiatus hernia, low lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, the acid pocket, obesity, increased distensibility of the esophagogastric junction, prolonged esophageal clearance, and delayed gastric emptying. Moreover, 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, duodenogastroesophageal reflux, longitudinal muscle contraction, mucosal integrity, and peripheral and central sensitization. Understanding the pathophysiology of GERD is important for future targets for therapy as proton pump inhibitor-refractory GERD symptoms remain a common problem…. It is clear that further research remains necessary despite the recent advances in the understanding of the pathophysiology of GERD."

Hetrick DC, Ciol MA, Rothman I et al. 2003.  Musculoskeletal dysfunction in men with chronic pelvic pain syndrome type III: a case-control study.  J Urol. 170(3):828-831.  “Men with CPPS have more abnormal pelvic floor muscular findings compared with a group of men without pain.  Abnormalities of the pelvic muscles may contribute to this pain syndrome.”

Heyes, M. P., K. Saito and S. P. Markey. 1992. Human macrophages convert L-tryptophan into the neurotoxin quinolinic acid. Biochem J 283(Pt. 3):633-635.

Hickey C, Thomas B. 2011. Delirium secondary to pregabalin. Gen Hosp Psychiatry. [Dec 14 Epub ahead of print]. "Fibromyalgia is a common and disabling disease, and treatment can be challenging. More recently, pregabalin has been approved to treat pain associated with fibromyalgia. ...Several case reports have documented delirium secondary to pregabalin, usually in older patients with multiple medical comorbidities and concurrent medications. We describe a case of delirium in a young patient without significant medical problems and in the absence of other potentially causal medications. In this case, pregabalin appears to be the single causal etiology for delirium. We recommend clinicians to consider the causal role it may play in any patient who presents with delirium."

Hicks GE, Morone N, Weiner DK. 2009. Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates. Spine. 34(12):1301-1306. "Results demonstrated that the presence of degenerative disc and facet pathology in older adults is ubiquitous, regardless of clinical status, with greater than 90% demonstrating some level of degeneration. Higher radiographic severity scores were associated with the presence of CLBP. In fact, presence of severe disc pathology was associated with 2-fold greater odds of having CLBP. But, radiographic severity of disc and facet disease was not associated with pain severity among those with CLBP." "From a research perspective, radiographic evaluation of spinal pathology provides additional information about older adults with CLBP compared to pain-free individuals, but its clinical utility for diagnostic purposes is still in question." [Spine generated pain no longer means surgery. It has been noted in many other research articles that pain in the elderly is undertreated. If facet or interlaminary injection can provide relief to some of these patients, more of their brain would be freed from pain processing. Aside from the humanitarian reasons, which are considerable, the economic considerations are huge. Some patients might regain a significant increase of mental and physical function. Some might be able to stay in their own homes longer, and some might be considerably less disabled. Insurance companies and lawyers, as well as doctors, take note. DJS]

Higgins DM, Fenton BT, Driscoll MA et al. 2017. Gender differences in demographic and clinical correlates among veterans with musculoskeletal disorders. Womens Health Issues. [Mar 18 Epub ahead of print.] "Studies suggest that women may be at greater risk for developing chronic pain and pain-related disability….. Because musculoskeletal disorders (MSD) are the most frequently endorsed painful conditions among veterans, we sought to characterize gender differences in sociodemographic and clinical correlates among veterans upon entry into Veterans Health Administration's Musculoskeletal Disorders Cohort….. Women were more likely to be younger, Black, unmarried, and veterans of recent conflicts. In analyses adjusted for gender differences in sociodemographics, women were more likely to have diagnoses of fibromyalgia, temporomandibular disorders, and neck pain. Almost one in five women (19.4%) had more than one MSD diagnosis, compared with 15.7% of men; this higher risk of MSD multimorbidity remained in adjusted analyses. Adjusting for sociodemographics, women with MSD were more likely to have migraine headache and depressive, anxiety, and bipolar disorders. Women had lower odds of cardiovascular diseases, substance use disorders, and several MSDs, including back pain conditions. Men were more likely to report "no pain" on the pain intensity Numeric Rating Scale, whereas more women (41%) than men (34%) reported moderate to severe pain (Numeric Rating Scale 4+)."

Hill Jr., C. S.  1996.  Government regulatory influences on opioid prescribing and their impact on the treatment of pain of nonmalignant origin.  J Pain Symptom Manage 11(5):287-298.

Hill Jr., C. S.  1995. When will adequate pain treatment be the norm?  JAMA 274 (23):1881-2. 

Hill, C. S. Jr. 1992 The intractable pain treatment act of Texas. Tex Med 88(2):70-72.

Hirsch JK, Sirois FM. 2014. Hope and fatigue in chronic illness: The role of perceived stress. J Health Psychol. [Mar 26 Epub ahead of print.] "Fatigue is a debilitating symptom of chronic illness that is deleteriously affected by perceived stress, a process particularly relevant to inflammatory disease. Hopefulness, a goal-based motivational construct, may beneficially influence stress and fatigue, yet little research has examined these associations. We assessed the relation between hope and fatigue, and the mediating effect of stress, in individuals with fibromyalgia, arthritis, and inflammatory bowel disease. Co-varying age, sex, and pain, stress partially mediated the association between hope and fatigue; those with greater hope reported less stress and consequent fatigue. Therapeutically, bolstering hope may allow proactive management of stressors, resulting in less fatigue." [Hope often comes with identifying the causes of the fatigue and treating them, and the focus should be towards this goal. DJS]

Hitchcock, L. S., B. R. Ferrell and M. McCaffery. 1994 The experience of chronic non-malignant pain J Pain Sympt Manage 9(5):312-318.

Hitscherich K, Smith K, Cuoco JA et al. 2016. The glymphatic-lymphatic continuum: Opportunities for osteopathic manipulative medicine. J Am Osteopath Assoc. 116(3):170-177."The brain has long been thought to lack a lymphatic drainage system. Recent studies, however, show the presence of a brain-wide paravascular system appropriately named the glymphatic system based on its similarity to the lymphatic system in function and its dependence on astroglial water flux. Besides the clearance of cerebrospinal fluid and interstitial fluid, the glymphatic system also facilitates the clearance of interstitial solutes such as amyloid-β and tau from the brain. As cerebrospinal fluid and interstitial fluid are cleared through the glymphatic system, eventually draining into the lymphatic vessels of the neck, this continuous fluid circuit offers a paradigm shift in osteopathic manipulative medicine. For instance, manipulation of the glymphatic-lymphatic continuum could be used to promote experimental initiatives for nonpharmacologic, noninvasive management of neurologic disorders. In the present review, the authors describe what is known about the glymphatic system and identify several osteopathic experimental strategies rooted in a mechanistic understanding of the glymphatic-lymphatic continuum."

Hiyama S, Ono T, Ishiwata Y et al. 2003.  Effects of experimental nasal obstruction on human masseter and suprahyoid muscle activities during sleep.  Angle Orthod. 73(2):151-157.  “Nasal obstruction could modulate the activities of the masseter and suprahyoid muscles during sleep.”  Activity of the suprahyoid muscles tended to increase significantly and the masseter tended to decrease significantly with nasal obstruction during sleep.  [This could affect TrPs, and also CPAP therapy for co-existing sleep apnea.  For the latter, it may indicate need for automatically adjusting CPAP set to maximum high equal to that of the sleep study need of the patient, rather than standard CPAP in some patients. DJS]

Hobson, J. A., R. Stickgold and E. F. Pace-Schott.  1998.  The neuropsychology of REM sleep dreaming.  NeuroReport 9(3):R1-R14. 

Hocking G, Cousins MJ. 2003.  Ketamine in chronic pain management: an evidence-based review.  Anesth Analg 97(6):1730-1739.  This review indicates evidence of increase of fibromyalgia pain relief, endurance, and decreased trigger point tenderness [one must assume that tender points are meant] with ketamine therapy, but with a narrow therapeutic window.  Perhaps other NMDA inhibitors such as dextromethorphan might have beneficial effect without the narrow therapeutic window, and/or might be used to enhance opioid treatment.

Hocking MJ. 2013. Exploring the central modulation hypothesis: do ancient memory mechanisms underlie the pathophysiology of trigger points? Curr Pain Headache Rep. 17(7):347. The author proposes that central nervous system-maintained global changes in alpha-motorneuron function, resulting from sustained plateau polarization, rather than local dysfunction of the motor endplate, underlie the pathogenesis of TrPs.

Hodges PW, Sapsford R, Pengel LH. 2007.  Postural and respiratory functions of the pelvic floor muscles.  Neurourol Urodyn. 26(3):362-371.  “This study provides evidence that the PFM (pelvic floor muscles) contribute to both postural and respiratory functions.”  [Although this article does not specifically site TrPs as part of this connection, they are involved.  Releasing the pelvic floor tightness, which is often caused by TrPs, may indirectly aid posture and respiration. DJS]

Hoffman D. 2015. Central and Peripheral Pain Generators in Women with Chronic Pelvic Pain: Patient Centered Assessment and Treatment. Curr Rheumatol Rev. 11(2):146-166. "Women with CPP (chronic pelvic pain) often present with several seemingly unrelated symptoms. This can be explained by co-existing chronic pain syndromes occurring in the same patient. Central sensitization occurs in all of these pain syndromes, also described as dysfunctional pain syndromes, and thus may explain why several often occur in the same patient. Six of the most common pain disorders that co-exist in CPP include endometriosis, painful bladder syndrome/interstitial cystitis, vulvodynia, myofascial pain/ pelvic floor hypertonus, irritable bowel syndrome, and primary dysmenorrhea. Central pain generators, (pain originating from CS) and peripheral pain generators, (pain from local tissue damage), can both occur in each of these six conditions….Chronic pain, specifically dysfunctional sensory processing, is recognized as a systemic disease process like diabetes to be managed as opposed to a local problem to be 'fixed' or cured."

Hoffman D. 2011. Understanding Multisymptom Presentations in Chronic Pelvic Pain: The Inter-relationships between the Viscera and Myofascial Pelvic Floor Dysfunction. Curr Pain Headache Rep. [Jul 8 Epub ahead of print]. "Patients presenting with chronic pelvic pain frequently complain of multiple symptoms that appear to involve more than one organ system, creating diagnostic confusion. The multisymptom presentation of chronic pelvic pain has been frequently described. This article describes four proposed explanations for the clinical observation of multisymptom presentations of patients with chronic pelvic pain. These include the concepts of viscerovisceral convergence; viscerosomatic convergence; hypertonicity of pelvic floor muscles creating visceral symptoms along with somatovisceral convergence; and central sensitization with expansion of receptive fields."

Hoffman DL, Dukes EM. 2007.  The health status burden of people with fibromyalgia: a review of studies that assessed health status with the SF-36 or the SF-12.  Int J Clin Pract. [Nov 24 Epub ahead of print].  “FM groups had similar or significantly lower (poorer) physical and mental health status scores compared to those with rheumatoid arthritis, osteoarthritis, osteoporosis, systemic lupus erythematosus, myofascial pain syndrome, primary Sjogren’s syndrome and others.  FM groups scored significantly lower than the pain condition groups mentioned above on domains of bodily pain and vitality.”  “People with FM had an overall health status burden that was greater in magnitude compared to people with other specific pain conditions that are widely accepted as impairing.”  [What does this indicate about those patients with FM AND CMP (and perhaps multiple other conditions)? DJS]

Hoffmann RG, Kotchen JM, Kotchen TA et al. 2010. Temporomandibular Disorders and Associated Clinical Comorbidities. Clin J Pain. [Dec 20 Epub ahead of print]. "The TMJD (temporomandibular joint and muscle disorders) -affected individuals were on average 41 years of age and predominantly female (90%). Nearly 60% of both men and women reported recent pain of moderate-to-severe intensity with a quarter of them indicating interference or termination of work-related activities. In the case-control comparison, a higher frequency of headaches, allergies, depression, fatigue, degenerative arthritis, fibromyalgia, autoimmune disorders, sleep apnea, and gastrointestinal complaints were prevalent among those affected with TMJD. Many of the associated comorbid conditions were over 6 times more likely to occur after TMJD was diagnosed. Among a wide array of treatments used (46 listed), the most effective relief for most affected individuals (91%) was the use of thermal therapies-hot/cold packs to the jaw area or hot baths. Nearly 40% of individuals affected with TMJD patients reported one or more surgical procedures and nearly all were treated with one or many different medications. Results of these treatments were generally equivocal. Although potentially limited to the most severe TMJD affected individuals, the survey results provide a comprehensive dataset describing the clinical manifestations of TMJD….The data provide evidence that TMJD represent a spectrum of disorders with varying pathophysiologies, clinical manifestations, and associated comorbid conditions. The findings underscore the complex nature of TMJD, the need for more extensive interdisciplinary basic and clinical research, and the development of outcome-based strategies to more effectively diagnose, prevent, and treat these chronic, debilitating conditions." [It is unfortunate that these patients were not assessed for co-existing myofascial trigger points, which can cause TMJD, are treatable, and are often components of other co-morbidities as well. DJS]

Holey LA, Dixon J. 2014. Connective tissue manipulation: A review of theory and clinical evidence. J Bodyw Move Ther. 18:112-118. "Connective tissue manipulation or connective tissue massage (bindegewebsmassage) is a manual reflex therapy in that it is applied with the therapist's hands which are in contact with the patient's skin. The assessment of the patient and the clinical decision-making that directs treatment is based on a theoretical model that assumes a reflex effect on the autonomic nervous system which is induced by manipulating the fascial layers within and beneath the skin to stimulate cutaneo-visceral reflexes. This paper reviews the literature and current research findings to establish the theoretical framework for CTM and the evidence for its clinical effects. The rationale for the principles of treatment is discussed and the evidence for the clinical effectiveness assessed through an analytical review of the clinical research." [This paper indicates to me that CTM would be an excellent therapy option for chronic myofascial pain. If fibromyalgia central sensitization were also involved, therapy would, as always, require modification. DJS]

Holman AJ, Neiman RA, Ettlinger RE. 2004. Preliminary efficacy of the dopamine agonist, pramipexole for fibromyalgia: the first, open label, multicenter experience. J Musculoskel Pain 12(1):69-74. Dopamine agonists may be promising pharmaceutical agents for the treatment of  FMS.

Holman AJ, Neradilek MB, Dryland DD et al. 2010. Patient-derived determinants for participation in placebo-controlled clinical trials for fibromyalgia. Curr Pain Headache Rep. 14(6):470-476. "Perspectives of patients with fibromyalgia influence their likelihood of participating in randomized placebo-controlled trials and potentially clash with current, well-established methodology of randomized controlled trial design. Mandates to use only acetaminophen for breakthrough pain and that require discontinuation of concomitant medications, especially in studies lacking an active comparator arm, could bias a trial cohort to thereby reduce the generalizability of study findings and conclusions. This study evaluates factors affecting willingness to participate in such clinical trials, including the impact of altruism, payment, study duration, forced discontinuation of specific medications, and subject demographics for patients seen by rheumatologists proficient and avidly interested in treating fibromyalgia." [This casts yet another shadow on current fibromyalgia research. DJS]

Holtedahl R. 2010. [Pregabalin for fibromyalgia – can we rely on the pharmaceutical industry?] Tidsskr Nor Laegeforen 130(10):1032-1036. [Norwegian] “Negative results were seldom mentioned in the abstracts, and secondary endpoints were reported incompletely. All 19 reviews referred to one or more of the clinical trials, and were generally limited to describing main results. Interpretation. Recommendations for pregabalin in treatment of patients with fibromyalgia are based on rather weak evidence. Until trials independent of industry-funding are published, the role of pregabalin in treatment of fibromyalgia remains unclear.”  

Holton KF, Taren DL, Bennett RM et al. 2010. The excitotoxin elimination diet: a novel dietary intervention for fibromyalgia patients. International Myopain Society Eighth Clinical Meeting Oct 3-7, 2010. Toledo, Spain. Abstract No. 47. "Results suggest that the excitotoxin elimination diet, with wider food choices than a living foods diet, can significantly improve symptoms in patients with FM. Future large scale testing of the dietary intervention is warranted." [This is exciting research on a preventable perpetuating factor for both fibromyalgia and myofascial pain. Do you have aspartame, MSG and other excitotoxins in your pantry? DJS]

Holton KF, Taren DL, Thomson CA et al. 2012. The effect of dietary glutamate on fibromyalgia and irritable bowel symptoms. Clin Exp Rheumatol [July 4 Epub ahead of print]. "To examine the effects of a challenge with monosodium glutamate (MSG) as compared to placebo on the symptoms of fibromyalgia (FM), in participants who initially experienced >30% remission of symptoms on an excitotoxin elimination diet....The MSG challenge, as compared to placebo, resulted in a significant return of symptoms (total symptom score.... These findings suggest that dietary glutamate may be contributing to FM symptoms in some patients. Future research on the role of dietary excitotoxins in FM is warranted." [Patients who routinely ingest aspartame, MSG and other excitotoxins take note. Diet is a perpetuating factor you can control. DJS]

Homma M, Ishikawa H, Kiuchi T. 2017. Illness perceptions and negative responses from medical professionals in patients with fibromyalgia: Association with patient satisfaction and number of hospital visits. Patient Educ Couns. [Aug 30 Epub ahead of print] "Treatment effectiveness and the respect accorded to patients were the key factors significantly correlated both with patient satisfaction and the number of hospital visits….Physicians should not emphasize only patients' negative psychological status but also should convey a respectful attitude and help patients understand their current treatment is useful."

Homma M, Ishikawa H, Kiuchi T. 2014. Association of physicians' illness perception of fibromyalgia with frustration and resistance to accepting patients: a cross-sectional study. Clin Rheumatol. [Aug 3 Epub ahead of print.] "The aim of this study was to elucidate whether physicians' illness perceptions correlate with their frustration or resistance to accepting patients with fibromyalgia (FM). In this cross-sectional postal survey, questionnaires were sent to member physicians of the Japan College of Rheumatology and Japan Rheumatism Foundation. Measures collected included the Brief Illness Perception Questionnaire with Causal Attribution, the Illness Invalidation Inventory, and the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10). Multiple logistic regression was performed to examine associations between the DDPRQ-10 and resistance to accepting patients with FM for treatment. We analyzed data from 233 physicians who had experience in consulting with patients with FM. Only 44.2 % answered that they wanted to accept additional patients with FM. Physicians' frustration was associated with difficulty controlling symptoms, patients' emotional responses, and causal attribution of FM to patient internal factors. Conversely, lower levels of frustration were associated with causal attributions to biological factors and uncontrollable external factors. However, the 'difficult patient' perception did not correlate with resistance to accepting patients with FM. Difficulty controlling symptoms with treatment was the one factor common to both physicians' frustration and resistance to accepting patients with FM. Physicians may hesitate to accept patients with FM not because of the stigmatic image of the 'difficult patient,' but instead because of the difficulty in controlling the symptoms of FM. Thus, to improve the quality of consultation, physicians must continuously receive new information about the treatments and causes of FM."

Hong CZ. 2013. Needling therapy for myofascial pain control. Evid Based Complement Alternat Med. [Aug 26 Epub ahead of print]. Needling in this context includes all therapies that include the use of a needle for penetration for medication injection or mechanical stimulation by needle alone (dry needling), including acupuncture and superficial needling. This paper specifically deals with needling for myofascial pain due to trigger points, and is written by a myofascial specialist who originally trained with David G. Simons. It touches on two review articles and seven original research papers. The use of the multiple insertion technique of dry needling is highlighted, as it can provide fast and efficient immediate pain control. During the injection, the needle is moved in and out, as it is positioned in different directions to find and treat multiple loci in the area. The author has modified this Travell-Boggs technique using a very fast method recommended by David Simons that avoids much of the muscle fiber damage due to side movement of the needle or the needle grab by the muscle. The immediate pain relief from multiple needle insertion is due to effects on the descending pain inhibitory system. A local twitch response (LTR) or the muscle grabbing of the needle (De-Qi effect) can signal the successful needle contact with each sensitive locus. It is important to find as many as possible to obtain maximum relief of pain. Needling key trigger points can inhibit satellite trigger point irritability and minimize central sensitization, so it is important to discover which trigger points are primary or "key."

Hong CZ. 2006.  Treatment of myofascial pain syndrome.  Curr Pain Headache Rep. 10(5):345-349.   “Effective MTrP therapies include manual therapies, physical therapy modalities, dry needling, or MTrP injection.  It is also important to eliminate any perpetuating factors and provide adequate education and home programs to patients so that recurrent or chronic pain can be avoided.”

Hong C. 2004.  Myofascial pain therapy.  J Musculoskeletal Pain 12(3/4):37-43.  “Myofascial pain should be appropriately treated to inactivate TrPs completely and to avoid recurrence permanently.”  This is a good overview of common options in the treatment of TrPs. 

Hong CZ. 2002.  New trends in myofascial pain syndrome. Zhonghua Yi Xue Za Zhi (Taipei) 65(11):501-12.  Review article. “The pathogenesis of [myofascial trigger points] MTrPs appears to be related to the integration in the spinal cord (formation of MTrP circuits) in response to the disturbance of the nerve endings and abnormal contractile mechanism at multiple dysfunctional endplates.”

Hong CZ. 2000.  Specific sequential myofascial trigger point therapy in the treatment of a patient with myofascial pain syndrome associated with reflex sympathetic dystrophy: commentary.  Australas Chiropr Osteopathy 9(1):7-11.

Hong CZ. 1996.  Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil. 77(11):1161-1166.  “Two weeks after injection, the degree of improvement in PT (pain threshold) or ROM (range of motion) (but not PI (pain intensity)) was not significantly different between two groups.  Post-injection soreness (different from myofascial pain) was more severe, developed sooner, and lasted longer in Group 1 than in Group 2.  Conclusion: Trigger point injection is a valuable procedure for pain relief for patients in both groups.  Patients with FMS are likely to experience significant but delayed and attenuated pain relief following injection of their active TrPs compared to myofascial pain patients with similar TrPs but without FMS.  aAlso, FMS patients are likely to experience significantly more post-injection soreness for a longer period of time.”

Hong CZ. 1994.  Lidocaine injection versus dry needling to myofascial trigger point.  The importance of the local twitch response.  Am J Phys Med Rehabil. 73(4):256-263.  “This study was designed to investigate the effects of injection with a local anesthetic agent or dry needling into a myofascial trigger point (TrP) of the upper trapezius muscle in 58 patients.  Trigger point injections with 0.5% lidocaine were given to 26 patients (Group I), and dry needling was performed on TrPs in 15 patients (Group II).  Local twitch responses (LTRs) were elicited during multiple needle insertions in both Groups I and II.  In another 17 patients, no LTR was elicited during TrP injection with lidocaine (9 patients, group Ia) or dry needling (8 patients, group IIa).  Improvement was assessed by measuring the subjective pain intensity, the pain threshold of the TrP and the range of motion of the cervical spine.  Significant improvement occurred immediately after injection into the patients in both group I and group II.  In Groups Ia and Ib, there was little change in pain, tenderness or tightness after injection.  Within 2-8 h after injection or dry needling, soreness (different from patients’ original myofascial pain) developed in 42% of the patients in group I and in 100% of the patients in group II.  Patients treated with dry needling had postinjection soreness of significantly greater intensity and longer duration than those treated with lidocaine injection.  The author concludes that it is essential to elicit LTRs during injection to obtain an immediately desirable effect.  TrP injection with 0.5% lidocaine is recommended, because it reduces the intensity and duration of postinjection soreness compared with that produced by dry needling.”

Hong CZ. 1994.  Persistence of local twitch response with loss of conduction to and from the spinal cord.  Arch Phys Med Rehabil. 75(1):12-16.  “These findings indicate that the transmission of LTR (local twitch response) depends mainly on the central nervous system with a possible minor degree of local transmission.”

Hong, C. Z. and D. G. Simons.  1998.  Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points.  Arch Phys Med Rehabil 79(7):863-72.

Hong JO, Park JS, Jeon DG et al. 2017. Extracorporeal shock wave therapy versus trigger point injection in the treatment of myofascial pain syndrome in the quadratus lumborum. Ann Rehabil Med. 41(4):582-588. This study from Korea found that extracorporeal shock waves were more effective than trigger point injection in treating pain from TrPs in the quadratus lumborum muscle, although both groups "demonstrated statistically significant improvements in pain and disability measures after treatment." Free Article

Hoog SL, Cheng Y, Elpers J et al. 2013. Duloxetine and pregnancy outcomes: safety surveillance findings. Int J Med Sci. 10(4):413-419. "While limitations of these data are recognized, the information available to date from these two data sources suggest that the frequency of abnormal outcomes reported in duloxetine pregnancy cases is generally consistent with the historic control rates in the general population." [This study was financed by Eli Lilly and Company, manufacturers of duloxetine]

Hoogwout SJ, Paananen MV, Smith AJ et al. 2015. Musculoskeletal pain is associated with restless legs syndrome in young adults. BMC Musculoskel Disord. 16(1):294. "Different dimensions of MSK (musculoskeletal) pain were associated with RLS in young adults, suggestive of shared pathophysiological mechanisms. Overlap between these conditions requires more clinical and research attention." Free PMC Article

Hopwood, M. B. and S. E. Abram.  1994.  Factors associated with failure of trigger point injections.  Clin J Pain 10:227-234. 

Horne,. J. and L. Reyner. 1999. Vehicle accidents related to sleep: a review. Occup Environ Med 56(5):289-94. 

Horning, M. R.  1997. Chronic opioids: a reassessment.  Alaska Med 39(4):103-110.  

Horowitz L, Sarkin JM. 1992.  Video display terminal operation: a potential risk in the etiology and maintenance of temporomandibular disorders.  Cranio. 10(1):43-50.  “TMD (temporomandibular disorder) is associated with numerous risk factors that commonly initiate sympathetic nervous system and stress hormone response mechanisms resulting in muscle spasms, trigger point formation, and pain in the head and neck.”

Horwitz S, Stewart A. 2015. An exploratory study to determine the relationship between cervical dysfunction and perimenstrual migraines. Physiother Can. 67(1):30-38. "Subjects with perimenstrual migraines were compared with controls on the basis of neck stiffness, trigger points, posture, range of motion, muscle strength, neural mobility and assessment of cervical joint mobility." There may be an association, according to these results, and more studies are needed.

Hoskin TL, Whipple MO, Nanda S et al. 2018. Longitudinal stability of fibromyalgia symptom clusters. Arthritis Res Ther. 20(1):37. In this Mayo Clinic study: Using self-report questionnaires of key fibromyalgia symptom domains (pain, fatigue, sleep disturbance, function, stiffness, dyscognition, depression, and anxiety), we previously identified four unique symptom clusters. The purpose of this study was to examine the stability of fibromyalgia symptom clusters between baseline and 2-year follow-up....More than half of participants (58%) remained in the same cluster at follow-up as at baseline.... Only two patients changed from high symptom intensity to low symptom intensity; similarly, only three moved from low to high.... Fibromyalgia patients classified into four unique symptom clusters based on the key domains of pain, fatigue, sleep disturbance, function, stiffness, dyscognition, depression, and anxiety showed moderate stability in cluster assignment after 2 years. Few patients moved between the two extremes of severity, and it was slightly more common to move to a lower symptom level than to worsen."

Hou C.R., Chung K.C., Chen J.T. et al. 2002. Effects of a calcium channel blocker on electrical activity in myofascial Trigger spots in rabbits. Am J Phys Med Rehabil 81(5):342-9. Calcium channel blockers are effective inhibitors of myofascial trigger point spontaneous electrical activity.

Hou C.R., Tsai L.C., Cheng K.F. et al. 2002.  Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity.  Arch Phys Med Rehabil 83(10):1406-14.  “Results suggest that therapeutic combinations such as hot pack plus active ROM and stretch with spray, hot pack plus active ROM and stretch with spray as well as TENS, and hot pack plus active ROM and interferential current as well as myofascial release technique, are most effective for releasing MtrP pain and increasing cervical ROM.”

Hou, C-R,  K-C Chung, J-T Chen. 1991. The effect of calcium channel blocker on spontaneous potentials of trigger points in rabbits: Clin J of Biomed Eng 18(3):143-149.

Houtmeyers, E., R. Gosselink, G. Gayan-Ramirez and M. Decramer.  1999.  Effects of drugs on mucus clearance.  Eur Respir J 14(2):452-67.

Howard KJ, Mayer TG, Neblett R et al. 2010. Fibromyalgia Syndrome in Chronic Disabling Occupational Musculoskeletal Disorders: Prevalence, Risk Factors, and Post treatment Outcomes. J Occup Environ Med. [Nov 30 Epub ahead of print]. "The CDOMD patients with fibromyalgia reported higher-level psychosocial distress. Women with fibromyalgia were 9.6 times less likely to return to work 1-year post treatment and, of those who did, were 4.3 times less likely to retain work....Of this cohort, 23.2% patients met criteria for fibromyalgia. Patients with fibromyalgia were found to show greater psychosocial distress and significantly poorer rates of work return and work retention 1-year post rehabilitation."

Howell ER. 2012. Conservative management of a 31 year old male with left sided low back and leg pain: a case report. J Can Chiropr Assoc. 56(3):225-232. "This case study reported the conservative management of a patient presenting with left sided low back and leg pain diagnosed as a left sided L5-S1 disc prolapse/herniation....A 31-year-old male recreational worker presented with left sided low back and leg pain for the previous 3-4 months that was exacerbated by prolonged sitting....The plan of management included interferential current, soft tissue trigger point and myofascial therapy, lateral recumbent manual low velocity, low amplitude traction mobilizations and pelvic blocking as necessary. Home care included heat, icing, neural mobilizations, repeated extension exercises, stretching, core muscle strengthening, as well as the avoidance of prolonged sitting and using a low back support in his work chair. The patient responded well after the first visit and his leg and back pain were almost completely resolved by the third visit....Conservative chiropractic care appears to reduce pain and improve mobility in this case of a L5-S1 disc herniation. Active rehabilitative treatment strategies are recommended before surgical referral."

Hoyle JA, Marras WS, Sheedy JE et al. 2010. Effects of postural and visual stressors on myofascial trigger point development and motor unit rotation during computer work. J Electromyogr Kinesiol. [Jun 25 Epub ahead of print]. "Musculoskeletal complaint rates are high among those performing low-level static exertions (LLSEs), such as computer users." "It was hypothesized that myofascial trigger point (MTrP) development might be one causal mechanism to help explain these complaints and that static postural and visual demands may be contributing factors." "…MTrPs developed after one hour of continuous typing, despite the stress condition." "Findings suggest that MTrPs may be one causal pathway for pain during LLSEs and both postural and visual demands may play a role in muscle activation patterns, perhaps attributing to MTrP development and resultant discomfort."

Hrebicek J, Janout V, Malincilova J, Horakova D, Cizek L. Detection of insulin resistance by simple quantitative insulin sensitivity check index QUICKI for epidemiological assessment and prevention.  J Clin Endocrinol Metab Jan;87(1):144-7.  

Hsieh C.Y., Hong C. Z., Adams A. H., Platt K. J. , Danielson C. D. , Hoehler F. K., and Tobis JS 2000. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil  81(3):258-64

Hsieh LF, Hong CZ, Chern SH et al. 2009.  Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius.  J Pain Symptom Manage. [Oct 10 Epub ahead of print].  “This study demonstrates that the diclofenac sodium patch was superior to the control patch in terms of reducing pain and improving functional outcomes, and did not result in significant adverse effects.”  [This may be a helpful option for patients with one or a small cluster of TrPs DJS]

Hsieh YL, Hong CZ, Liu SY et al. 2016. Acupuncture at distant myofascial trigger spots enhances endogenous opioids in rabbits: a possible mechanism for managing myofascial pain. Acupunct Med. [May 3 Epub ahead of print.] "This study demonstrates that interactions within the endogenous opioid system may be involved in the remote effects of acupuncture."

Hsieh YL, Kao MJ, Kuan TS et al. 2007.  Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs.  Am J Phys Med Rehabil. 86(5):397-403.  “This study supports the concept that activity in a primary MTrP leads to the development of activity in satellite MTrPs and the suggested spinal cord mechanism responsible for this phenomenon.”

Hsieh YL, Yang CC, Liu SY et al. 2014. Remote dose-dependent effects of dry needling at distant myofascial trigger spots of rabbit skeletal muscles on reduction of substance p levels of proximal muscle and spinal cords. Biomed Res Int. 2014:982121. This remote effect of dry needling involves the reduction of SP levels in proximal muscle and spinal superficial laminaes, which may be closely associated with the control of myofascial pain. Free Article

Hsieh YL, Yang SA, Yang CC et al. 2012. Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemicals associated with pain, inflammation, and hypoxia. Evid Based Complement Alternat Med. 2012:342165. "Dry needling at the MTrSs modulates various biochemicals associated with pain, inflammation, and hypoxia in a dose-dependent manner."

Hsin ST, Yin YC, Juan CH et al. 2002.  Myofascial pain syndrome induced by malpositioning during surgery – a case report.  Acta Anaesthesiol Sin. 40(1):37-41.  “It is a real challenge to the anesthesiologists to differentiate brachial plexus injury (BPI) from myofascial pain syndrome (MPS).  The possibility of MPS should be suspected in a patient with complaints of pain and dysfunction of the upper arm immediately after surgery.  Here we report a case of gallstone with cervical ankylosing spondylitis who sustained myofascial pain syndrome immediately after open cholecystectomy.  We utilized dry needle stimulation to deactivate the trigger point of the pectoris minor muscle and stretching the muscle to relieve the muscle pain after the diagnosis was made.  The patient completely recovered 2 weeks later.”

Hsueh, T. C., S. Yu, T. S. Kuan and C. Z. Hong.  1998.  Association of active myofascial trigger points and cervical disc lesions.  J Formos Med Assoc 97(3):174-180.

Hsueh, T-C. , P. T. Cheng, T. S. Kuan and C-Z Hong. 1997. The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points.  1997. Am J Phys Med Rehabil 76(6):471-476.

Huang CY, Chen YL, Li AH et al. 2014. Minocycline, a microglial inhibitor, blocks spinal CCL2-induced heat hyperalgesia and augmentation of glutamatergic transmission in substantia gelatinosa neurons. Neuroinflammation. 11(1):7. This study in rats found that injecting minocycline, a specific inhibitor of microglial activation, provided pain relief in rats with induced central sensitization.

Huang CY, Chung SD, Kao LT et al. 2015. Statin use is associated with bladder pain syndrome/interstitial cystitis: A population-based case-control study. Urol Int. [Jul 16 Epub ahead of print.] "Statin may induce epithelial dysfunction of the bladder urothelium. Epithelial dysfunction was proposed as one of the major potential etiologies for bladder pain syndrome/interstitial cystitis (BPS/IC). In this study, we examined the association between statin use and BPS/IC using a population-based study….We concluded that there was an association between statin use and BPS/IC."

Huang H, Deb A, Culbertson C et al. 2015. Dermatological manifestations of postural tachycardia syndrome are common and diverse. J Clin Neurol. [Nov 26 Epub ahead of print.] "Postural tachycardia syndrome (POTS) is a syndrome of orthostatic intolerance in the setting of excessive tachycardia with orthostatic challenge, and these symptoms are relieved when recumbent. Apart from symptoms of orthostatic intolerance, there are many other comorbid conditions such as chronic headache, fibromyalgia, gastrointestinal disorders, and sleep disturbances. Dermatological manifestations of POTS are also common and range widely from livedo reticularis to Raynaud's phenomenon….The most commonly reported symptom was rash (77%). Raynaud's phenomenon was reported by over half of the patients, and about a quarter of patients reported livedo reticularis. The rash was most commonly found on the arms, legs, and trunk. Some patients reported that the rash could spread, and was likely to be pruritic or painful. Very few reported worsening of symptoms on standing….The results suggest that dermatological manifestations in POTS vary but are highly prevalent, and are therefore of important diagnostic and therapeutic significance for physicians and patients alike to gain a better understanding thereof. Further research exploring the underlying pathophysiology, incidence, and treatment strategies is necessary." Free Article

Huang H, Hohler AD. 2015. The dermatological manifestations of postural tachycardia syndrome: A review with illustrated cases. Am J Clin Dermatol. Aug 5. [Epub ahead of print] "Postural tachycardia syndrome (POTS) is a syndrome of excessive tachycardia with orthostatic challenge, and relief of such symptoms with recumbence. There are several proposed subtypes of the syndrome, each with unique pathophysiology. Numerous symptoms such as excessive tachycardia, lightheadedness, blurry vision, weakness, fatigue, palpitations, chest pain, and tremulousness are associated with orthostatic intolerance. Other co-morbid conditions associated with POTS are not clearly attributable to orthostatic intolerance. These include chronic headache, fibromyalgia, functional gastrointestinal or bladder disorders, cognitive impairment, and sleep disturbances. Dermatological manifestations of POTS are also common and wide ranging, from livedo reticularis to Raynaud's phenomenon, from cutaneous flushing to erythromelalgia. Here, we provide three illustrative cases of POTS with dermatological manifestations."

Huang JT, Chen HY, Hong CZ et al. 2014. Lumbar facet injection for the treatment of chronic piriformis myofascial pain syndrome: 52 case studies. Patient Prefer Adherence. 8:1105-1111. "It is important to identify the possible cause of piriformis myofascial pain syndrome. If this pain is related to lumbar facet lesions, lumbar facet joint injection can immediately suppress piriformis myofascial pain symptoms. This effectiveness may last for at least 6 months in most patients. This study further supports the importance of eliminating the underlying etiological lesion for complete and effective relief of myofascial pain syndrome."

Huang QM, Liu L. 2014. Wet needling of myofascial trigger points in abdominal muscles for treatment of primary dysmenorrhoea. Acupunct Med. 32(4):346-349. "Primary dysmenorrhoea was significantly reduced 1 year after wet needling to MTrPs in the abdominal region and home stretching exercises, justifying further research with controlled trials."

Huang QM, Lv JJ, Ruanshi QM et al. 2015. Spontaneous electrical activities at myofascial trigger points at different stages of recovery from injury in a rat model. Acupunct Med. [May 13 Epub ahead of print.] "Background: Spontaneous electrical activity (SEA) is a feature of myofascial trigger points (MTrPs), which can either be latent or active. However, SEA at different stages of recovery from MTrPs remains unclear....Conclusions: Increasing recovery periods following a MTrP modeling intervention in rats are characterized by different frequencies and amplitudes of SEA from TBs (taut bands)."

Huang QM, Ye G, Zhao ZY et al. 2013. Myoelectrical activity and muscle morphology in a rat model of myofascial trigger points induced by blunt trauma to the vastus medialis. Acupunct Med. 31(1):65-73. "A total of 24 male SD rats were randomly divided into a control group (group A) and model group (group B). A blunt striking injury and eccentric exercise were applied to the vastus medialis (VM) of rats in group B for 8 weeks. Later, the palpable taut band (TB), local twitch response, myoelectrical activities and morphology in the two groups were examined….An average of 2.5 (30/12) palpable TBs were detected in the VM in group B compared with none in group A. The MTrPs had two types of abnormal potential. Their amplitudes were significantly higher than those in the control group…but their durations showed no significant differences. A series of reflex contractions appeared in groups A and B in response to external stimulation to the ear. Their amplitude and duration in group B were significantly lower than those in group A. A series of lower fibrillation potentials repeatedly occurred in model MTrPs in group B. The morphology of MTrPs showed abnormal muscle fibres with large round or ellipse shapes in cross-section and enlarged tapering shapes in longitudinal section….Active MTrPs can be provoked by repeated blunt injury. Active MTrPs are a group of muscle fibres with abnormal shapes and abnormal myoelectrical potentials. External stimulation provokes low-voltage responses in MTrPs, which is different from the response of normal muscle fibres.

Huang Y, Li Y, Zhong X et al. 2017. Src-family kinases activation in spinal microglia contributes to central sensitization and chronic pain after lumbar disc herniation. Mol Pain. 13:1744806917733637. "These findings suggested that central sensitization was involved in radicular pain from lumbar disc herniation; src-family kinases-mediated inflammatory response may be responsible for central sensitization and chronic pain after lumbar disc herniation."

Huang YT, Lin SY, Neoh CA et al. 2011. Dry needling for myofascial pain: prognostic factors. J Altern Complement Med. 17(8):755-762. "Dry needling is an effective treatment for reducing pain and pain interference. However, long pain duration, high pain intensity, poor quality of sleep, and repetitive stress are associated with poor outcomes. Treatment outcome depends not only on the dry needling protocol, but also on disease characteristics and patient demographic profile." [Outcome would also depend on the proper identification of the myofascial trigger points involved, as well as the training and skill of the practitioner. DJS]

Huang YJ, Grau JW. 2018. Ionic plasticity and pain: The loss of descending serotonergic fibers after spinal cord injury transforms how GABA affects pain. Exp Neurol. 306:105-116."Activation of pain (nociceptive) fibers can sensitize neural circuits within the spinal cord, inducing an increase in excitability (central sensitization) that can foster chronic pain. The development of spinally-mediated central sensitization is regulated by descending fibers and GABAergic interneurons." [This animal study showed that ionic transfer within the spinal cord can change after exposure to pain, leading to central sensitization. DJS]

Hubbard, D. R. and G. M. Berkoff.  1993.  Myofascial trigger points show spontaneous needle EMG activity.  Spine 18(13):1803-7.  Sustained spontaneous EMG activity was found in the 1-2 mm nidus of all TrPs, and was absent in non-TrPs.

Hubbell, S. L. and M. Thomas.  1985.  Postpartum cervical myofascial pain syndrome: review of four patients.  Obstet Gynecol 65(3 Suppl):56S-57S.

Huber J, Lisiñski P, Polowczyk A. 2013. Reinvestigation of the dysfunction in neck and shoulder girdle muscles as the reason of cervicogenic headache among office workers. Disabil Rehabil. 35(10):793-802. This study from Poland investigated: "Dysfunction of cervical and shoulder girdle muscles as reason of cervicogenic headache (CEH) was reinvestigated with clinical and neurophysiological studies….Forty office workers were randomized into two groups to verify efficiency of supervised kinesiotherapy (N = 20) aimed with improvement of muscle's activity and headache symptoms releasing. Headache intensity was evaluated with visual analog scale (VAS), range of cervical movement (ROM) with goniometer, trigger points (TrPs) incidence with palpation and muscle's strength with Lovett's scale. Reaction of patients for muscle's elongation was also evaluated. Surface electromyographical recordings were bilaterally analyzed at rest (rEMG) and during maximal contraction (mcEMG)….Deficits of cervical flexion and muscles strength were found in all patients. TrPs occurred predominantly in painful trapezius muscle. Incidence of trigger points coexisted with intensity of CEH. Results indicated on muscles dysfunction which improved only after supervised therapy. Positive correlations between increase in rEMG amplitudes and high VAS scores, high-amplitude rEMG recordings incidence and increased number of TrPs were found. Negative correlation was detected between amplitude in mcEMG and amplitude of rEMG recordings…Dysfunction of trapezius muscle was most responsible for CEH etiology. Proposed algorithm of kinesiotherapy was effective as complementary method of the CEH patients' treatment."

Huber R, Ghilardi MF, Massimini M et al.  2004.  Local sleep and learning.  Nature 430(6995):78-81. The amount of slow-wave activity in right brain areas can help consolidate new learning.  It is important for medical teams to help FMS patients regain deep level sleep.

Hudson JI, Arnold LM, Bradley LA et al. 2009.  What makes patients with fibromyalgia feel better?  Correlations between patient global impression of improvement and changes in clinical symptoms and function: a pooled analysis of four randomized placebo-controlled trials of duloxetine.  J Rheumatol. 36(11):2517-2522.  “In addition to pain reduction, what makes patients with FM feel better may include improvement in fatigue, physical functioning, mood, and impact on daily living.  An assessment of these domains may be important in clinical trials of FM and in the management of patients with FM.”

Hudson JL, Arnold LM, Keck PE et al. 2004.  Family study of fibromyalgia and affective spectrum disorder.  Biol Psychiatry 56(11):884-891.  This study found that FMS was associated with the other medical and psychiatric disorders that are proposed to be grouped as affective spectrum disorder.  [Since FMS does not cover a homogenous group, lumping it as such with a group of medical and psychiatric disorders could add to the confusion. DJS]

Hudson J.I., Mangweth B., Pope H.G. et al.  Family study of affective spectrum disorder.  Arch Gen Psychiatry.  This study suggests that some disorders such as ADHD, IBS, migraine, OC, PTSD, fibromyalgia and other conditions may share a genetic predisposition, as these conditions are often found clustered in families.

Hudson, N., M. A. Fitzcharles, M. Cohen, M. R. Starr and J. M. Esdaile.  1998.  The association of soft-tissue rheumatism and hypermobility.  Br J Rheumatol 37(4):382-6.  

Hudson, T.  2000.  Fibrocystic breasts.  Women’s Health Update.  Townsend Letter for Doctors & Patients Jan:142-3.

Huggins T, Boras AL, Gleberzon BJ et al. 2012. Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders: a systematic review of the literature. J Can Chiropr Assoc. 56(1):49-57. "This systematic review of eight clinical trials involving the use of the AAI found reported benefits to patients with a spinal pain and trigger points, although the clinical trials reviewed suffered from many methodological limitations, including small sample size, relatively brief follow-up period and lack of control or sham treatment groups."

Hughes G, Martinez C, Myon E et al. 2005.  The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice.  Arthritis Rheum. 54(1):177-183.  “Being diagnosed as having FM may help patients cope with some symptoms, but the diagnosis has a limited impact on health care resource use in the longer term, possibly because there is little effective treatment.”  [This could also be because insurance companies do not cover nor many health care resources provide effective treatment regiments. DJS]

Hughes KH. 1998. Painful rib syndrome. A variant of myofascial pain syndrome. AAOHN J. 46(3):115-120.

Hulens M, Rasschaert R, Dankaerts W et al. 2018. Spinal fluid evacuation may provide temporary relief for patients with unexplained widespread pain and fibromyalgia. Med Hypotheses. 118:55-58. "Fibromyalgia (FM) exhibits characteristics of a neurological disorder, and similarities have been identified between FM and idiopathic intracranial hypertension (IICH). When intracranial pressure rises, the drainage of excess cerebrospinal fluid (CSF) through the subarachnoid space of the cranial and spinal nerves increases. Higher CSF pressure irritates nerve fibers inside nerve root sheaths and may consequently cause radicular pain, as was reported in patients with IICH. Moreover, the cut-off of 20-25?cm H20 used to define IICH may be too high, as has been suggested in patients with chronic fatigue syndrome. We hypothesize that the neurological symptoms of FM are caused by the dysregulation of cerebrospinal pressure (CSP) and that spinal fluid drainage can relieve this pain. Exploring the processes underlying increased CSP may provide an alternative explanation for the generation of unexplained widespread pain (WSP) and FM as opposed to central sensitization. Additionally, when performing a lumbar puncture for diagnostic reasons, it is useful to measure opening pressure in patients with chronic WSP." [Many FM patients have symptoms of excess cranial pressure. I am one. Some of that can be relieved by myofascial TrP work on the dural tube attachments, including the crura. Some can be relieved by work on TrPs that may be hampering the drainage of the glymphatic system. DJS]

Humphreys BK, Kenin S, Hubbard BB et al. 2003.  Investigation of connective tissue attachments to the cervical spinal dura mater.  Clin Anat. 16(2):152-159.  Common but previously unremarked connective tissue attachments originating from the nuchal ligament and rectus capitis posterior minor muscle to the dura may play a significant role in neck pain.

Hunter C, Dubois M, Zou S et al. 2009.  A new muscle pain detection device to diagnose muscles a source of back and/or neck pain.  Pain Med. [Dec 16 Epub ahead of print].  “…a Muscle Pain Detection Device (MPDD) has been developed.  A muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain as well as distinguishing other functional muscle pain thought to cause MPS.”  “Using the MPDD appears to be more valid and potentially more reliable than palpation to identify muscles causing regional pain that could benefit from injections.”  [It might be useful and effective to teach palpation skills in medical, dental and other health care schools. DJS]

Huntley AH, Srbely JZ, Zettel JL. 2015. Experimentally induced central sensitization in the cervical spine evokes postural stiffening strategies in healthy young adults. Gait Posture. [Jan 24 Epub ahead of print.] "Dysequilibrium of cervicogenic origin can result from pain and injury to cervical paraspinal tissues post-whiplash; however, the specific physiological mechanisms still remain unclear. Central sensitization is a neuradaptive process which has been clinically associated with conditions of chronic pain and hypersensitivity. Strong links have been demonstrated between pain hypersensitivity and postural deficits post-whiplash; however, the precise mechanisms are still poorly understood. The purpose of this study was to explore the mechanisms of cervicogenic disequilibrium by investigating the effect of experimentally induced central sensitization in the cervical spine on postural stability in young healthy adults." The results of this study suggest that the body stiffens in reaction to sensitizing spinal stimulation. "Future studies need to further explore this relationship in clinical (whiplash, chronic pain) populations." [This stiffening may be part of the formation of myofascial trigger points. DJS]

Huppe A, Brockow T, Raspe H. 2004.  [Chronic widespread pain and tender points in low back pain: a population-based study].  Z Rheumatol 63(1):76-83.  [German]  These researchers did not find fibromyalgia to be a common and significant factor in low back pain. 

Hurtig IM, Raak RI, Kendall SA, Gerdle B, Wahren LK. Quantitative sensory testing in fibromyalgia patients and in healthy subjects: identification of subgroups. Clin J Pain Dec:17(4):316-22,2001.  There are distinct subgroups of FMS patients that have different cold pain thresholds. These groups have differences in sleep quality, pain intensity, and number of tender points.

Huskey AM, Thomas CC, Waddell JA. 2013. Occurrence of milnacipran-associated morbilliform rash and serotonin toxicity. Ann Pharmacother. 47(7-8):e32. "A 57-year-old white female presented to the emergency department because of a full-body morbilliform rash, which appeared 9 days after initiation of milnacipran 50 mg twice daily. In the emergency department the patient's vital signs were: heart rate 121 beats/min, blood pressure 180/100 mm Hg, and temperature 38.9° C. The patient reported diarrhea, nausea, dizziness, restlessness, and increased muscle pain. Her history included recurrent breast cancer first diagnosed in 1999, hypertension, fibromyalgia, depression, osteopenia, gastroesophageal reflux disease, insomnia, and endometriosis. Her home medications included milnacipran, fluoxetine, alprazolam, zolpidem, zoledronic acid, anastrozole, doxepin, ranitidine, levocetirizine, doxazosin, tramadol, vitamin D, and ferrous gluconate. The patient's increased heart rate, blood pressure, and temperature, as well as restlessness, self-reported diarrhea and nausea, and self-reported increase in muscle pain, indicated serotonin toxicity. Milnacipran, fluoxetine, and tramadol were discontinued, while doxepin was continued. Treatment consisted of acetaminophen, diphenhydramine, methylprednisolone, promethazine, and hydralazine 10 mg intravenously. The following morning all vital signs were within normal limits and the patient's diarrhea, nausea, dizziness, restlessness, and muscle pain resolved. She was discharged the following morning. The rash had resolved after day 2 of hospital discharge, which was the fourth day after discontinuation of milnacipran….It is important to increase awareness of the possibility of developing morbilliform rash and serotonin toxicity with milnacipran therapy, as both conditions can be associated with poor outcomes if not detected early and treated appropriately."

Hussain SA, Al-Khalifa II, Jasim NA et al. 2010. Adjuvant use of melatonin for treatment of fibromyalgia. J Pineal Res. [Dec 16 Epub ahead of print]. "Using melatonin (3mg or 5mg/day) in combination with 20 mg/day fluoxetine resulted in significant reduction in both total and different components of FIQ score compared to the pretreatment values. In conclusion, administration of melatonin, alone or in a combination with fluoxetine, was effective in the treatment of patients with FMS."

Huston P, McFarlane B. 2016. Health benefits of tai chi: What is the evidence? Can Fam Physician. 62(11):881-890. "Systematic reviews of tai chi for specific conditions indicate excellent evidence of benefit for preventing falls, osteoarthritis, Parkinson disease, rehabilitation for chronic obstructive pulmonary disease, and improving cognitive capacity in older adults. There is good evidence of benefit for depression, cardiac and stroke rehabilitation, and dementia. There is fair evidence of benefit for improving quality of life for cancer patients, fibromyalgia, hypertension, and osteoporosis. Current evidence indicates no direct benefit for diabetes, rheumatoid arthritis, or chronic heart failure. Systematic reviews of general health and fitness benefits show excellent evidence of benefit for improving balance and aerobic capacity in those with poor fitness. There is good evidence for increased strength in the lower limbs. There is fair evidence for increased well-being and improved sleep. There were no studies that found tai chi worsened a condition. A recent systematic review on the safety of tai chi found adverse events were typically minor and primarily musculoskeletal; no intervention-related serious adverse events have been reported."

Huysmans MA, Hoozemans MJ, van der Beek AJ et al. 2007.  Fatigue effects of tracking performance and muscle activity.  [Jan 5 Epub ahead of print] J Electromyogr Kinesiol.

Hwang M, Kang YK, Shin JY et al. 2005.  Referred pain pattern of the abductor pollicis longus muscle. Am J Phys Med Rehabil. 84(8):593-597.  “Referred pain patterns of the abductor pollicis longus resemble pain experienced in de Quervain’s tenosynovitis.  Thus, identification of the abductor pollicis longus trigger point should be considered in pain of the radial aspect of the wrist and thumb, especially when no other neurologic abnormalities or inflammatory conditions are present.”

Hwang M, Kang YK, Kim DH. 2005.  Referred pain pattern of the pronator quadratus muscle.  Pain [Epub ahead of print June 16th]  This paper describes two main pain patterns of pronator quadratus myofascial trigger points.

Iacovides S, Avidon I, Baker FC. 2015. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. [Sep 7 Epub ahead of print.] "Women with dysmenorrhea, compared with women without dysmenorrhea, have greater sensitivity to experimental pain both within and outside areas of referred menstrual pain. Importantly, the enhanced pain sensitivity is evident even in phases of the menstrual cycle when women are not experiencing menstrual pain, illustrating that long-term differences in pain perception extend outside of the painful menstruation phase. This enhanced pain sensitivity may increase susceptibility to other chronic pain conditions in later life; dysmenorrhea is a risk factor for fibromyalgia. Further, dysmenorrheic pain has an immediate negative impact on quality of life, for up to a few days every month. Women with primary dysmenorrhea have a significantly reduced quality of life, poorer mood and poorer sleep quality during menstruation compared with their pain-free follicular phase, and compared with the menstruation phase of pain-free control women. The prescribed first-line therapy for menstrual pain remains non-steroidal anti-inflammatory drugs, which are effective in relieving daytime and night-time pain….Further study is needed to determine whether effectively blocking dysmenorrheic pain ameliorates risk for the development of chronic pain disorders and to explore whether it is possible to prevent the development-and not just treat-severe dysmenorrheic pain in adolescent girls."

Iannuccelli C, Guzzo MP, Atzeni F et al. 2017. Pain modulation in patients with fibromyalgia undergoing acupuncture treatment is associated with fluctuations in serum neuropeptide Y levels. Clin Exp Rheumatol. [May 31 Epub ahead of print] "Neuropeptide Y (NPY) is a neurotransmitter released by sympathetic neurons, which is probably involved in pain modulation. Acupuncture is increasingly used as an alternative or complementary means of controlling pain in rheumatic diseases such as fibromyalgia (FM), a chronic widespread pain syndrome accompanied by allodynia and hyperalgesia. … The baseline serum NPY levels of the patients were higher than those of the controls. They had significantly increased by the end of the treatment, when there was also a statistically significant reduction in pain, the number of tender points number, and the clinimetric scores….These findings confirm the analgesic properties of acupuncture as a complementary treatment in FM, and indicate that NPY could play a role in pain modulation."

Iannuccelli C, Spinelli FR, Guzzo MP et al. 2012. Fatigue and widespread pain in systemic lupus erythematosus and Sjogren's syndrome: symptoms of the inflammatory disease or associated fibromyalgia? Clin Exp Rheumatol. 30(6 Suppl 74):117-121. "FM seems to contribute to constitutional symptoms more in SLE than in pSS, suggesting a different underlying cause of fatigue and widespread pain in these two different connective tissue diseases."

Ibarra JM, Ge HY, Wang C et al. 2011. Latent Myofascial Trigger Points are Associated with an Increased Antagonistic Muscle Activity during Agonist Muscle Contraction. J Pain. [Nov 9 Epub ahead of print]. "The current study provides the first evidence that increased motor unit excitability is associated with reduced antagonist reciprocal inhibition." Even with latent TrPs, this inhibition existed. This "may contribute to the delayed and incomplete muscle relaxation following exercise. Disordered fine movement control, and unbalanced muscle activation. Elimination of latent MTrPs and/or prevention of latent MTrPs from becoming active may improve motor functions."

Ichesco E, Bhavsar R, Clauw DJ et al. 2014. Altered resting state connectivity of the insular cortex in individuals with fibromyalgia. J Pain. [May 7 Epub ahead of print.] "The insular (IC) and cingulate cortices (CC) are critically involved in pain perception. Previously we demonstrated that fibromyalgia (FM) patients have greater connectivity between the insula and Default Mode Network at rest, and that changes in the degree of this connectivity were associated with changes in the intensity of ongoing clinical pain. Here we more thoroughly evaluate the degree of resting state connectivity to multiple regions of the IC in individuals with FM and healthy controls (HC). We also investigated the relationship between connectivity, experimental pain and current clinical chronic pain. Functional connectivity was assessed using resting state functional magnetic resonance imaging in 18 FM patients and 18 age- and sex-matched HC using pre-defined seed regions in the anterior, middle and posterior IC. FM patients exhibited greater connectivity between: (1) right mid IC and right mid/posterior CC and right mid IC; (2) right posterior IC and the left CC; and (3) right anterior IC and left superior temporal gyrus. HCs displayed greater connectivity between: left anterior IC and the bilateral medial frontal gyrus/ACC; and left posterior IC and the right superior frontal gyrus. Within the FM group, greater connectivity between the IC and CC was associated with decreased pressure-pain thresholds.… These data provide further support for altered resting-state connectivity between the IC and other brain regions known to participate in pain perception/modulation playing a pathogenic role in conditions such as FM. We speculate that altered IC connectivity is associated with the experience of chronic pain in individuals with fibromyalgia."

Ickmans K, Meeus M, De Kooning M et al. 2015. Associations between cognitive performance and pain in chronic fatigue syndrome: Comorbidity with fibromyalgia does matter. Pain Physician. 18(5):E841-E852. "The cross-sectional nature of this study does not allow for inferences of causation….The results underline disease heterogeneity in CFS by indicating that a measure of endogenous pain inhibition might be a significant predictor of cognitive functioning in CFS patients with FM, while self-reported pain appears more appropriate to predict cognitive functioning in CFS patients without FM."

Igaz P, Novak I, Lazaar E et al. 2001.  Bidirectional communication between histamine and cytokines.  Inflamm Res. 50(3):123-128.  “Histamine plays fundamental roles in numerous immune reactions.  In addition to its well-characterized effects in the acute inflammatory and allergic responses, histamine also influences the expression and actions of several cytokines.  Because antihistamines are widely used in the treatment of various human diseases, this complex interaction could have general medical relevance too.”

Iglebekk W, Tjell C, Borenstein P. 2017. Treatment of chronic canalithiasis can be beneficial for patients with vertigo/dizziness and chronic musculoskeletal pain, including whiplash related pain. Scand J Pain. 8(1):1-7. "The present study has shown that repositioning of otoliths in the SCCs in nearly all patients with chronic BPPV/canalithiasis ameliorated pain and other symptoms. The correlation between vertigo/dizziness and the majority of symptoms was significant. Therefore, there is strong evidence to suggest that there is a connection between chronic BPPV/canalithiasis and chronic pain as well as the above-mentioned symptoms... Patients with unexplained pain conditions should be evaluated with the Dizziness Handicap Inventory-questionnaire, which can identify treatable balance disorders." [This is another possible option for FM patients with symptoms of dizziness/vertigo.]

Iglesias-Gonzalez JJ, Munoz-García MT, Rodrigues-de-Souza DP et al. 2013. Myofascial trigger points, pain, disability, and sleep quality in patients with chronic nonspecific low back pain. Pain Med. 14(12):1964-1970.. "Forty-two patients with nonspecific LBP (low back pain) (50% women), aged 23-55 years old, and 42 age- and sex-matched controls participated….TrPs were bilaterally explored within the quadratus lumborum, iliocostalis lumborum, psoas, piriformis, gluteus minimus, and gluteus medius muscles in a blinded design. TrPs were considered active if the subject recognized the local and referred pain as familiar symptoms, and TrPs were considered latent if the pain was not recognized as a familiar symptom. Pain measures were collected with a numerical pain rate scale, disability was assessed with the Roland-Morris questionnaire, and sleep quality was determined with the Pittsburgh Sleep Quality Index….The local and referred pain elicited by active TrPs in the back and hip muscles contributes to pain symptoms in nonspecific LBP. Patients had higher disability and worse sleep quality than controls. The number of active TrPs was associated with pain intensity and sleep quality. It is possible that a complex interaction among these factors is present in patients with nonspecific LBP."

Ignatowski TA, Spengler RN. 2004.  Tumor necrosis factor-alpha quantification and expression by insitu hybridization.  Methods Mol Biol 196:85-96.  Antidepressants may work as pain relievers by inhibiting production of the inflammatory protein tumor necrosis factor in the brain.

Iguchi M., Katoh Y., Koike H. et al. 2002.  Randomized trial of trigger point injection for renal colic.  Int J Urol 9(9):475-479.  “Trigger point injection, in our experience, is an easy, safe and effective method for the amelioration of renal colic."

Iida K, Oguma Y. 2013. Relationships between flow experience, IKIGAI, and sense of coherence in tai chi practitioners. Holist Nurs Pract. 27(5):260-267. "The purpose of this study was to examine the mental health effects of Tai chi on regular practitioners by investigating the relationships between flow experience, IKIGAI (Japanese: "Life worth living"), and sense of coherence. The results indicated that flow experience may influence IKIGAI and IKIGAI may influence sense of coherence; this suggests that IKIGAI may act as an intermediary between flow experience and sense of coherence. The results also indicated that the longer the Tai chi experience, the higher was the flow experience."

Ikeda H, Murase K. 2004.  Glial nitric oxide-mediated long-term presynaptic facilitation revealed by optical imaging in rat spinal dorsal horn.  J Neurosci. 24(44):9888-9896.  “Activity-dependent LTP of nociceptive afferent synaptic transmission the spinal cord is believed to underlie central sensitization after inflammation nerve injury. This glial NO-mediated control of presynaptic excitation may contribute to the induction at least in part.”

Iliff JJ, Wang M, Liao Y et al. 2012. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amaloid beta. Sci Transi Med. 4(147):147ra111. The brain does not have a lymph system. It needs another way to clear extra cellular proteins and drain excess interstitial fluid and other waste materials. Material dissolves in the cerebrospinal fluid (CSF), and then "...a substantial portion of subarachnoid CSF cycles through the brain interstitial space...." and then cleared though paravenous drainage pathways. " clearance through paravenous flow may also regulate extracellular levels of proteins involved with neurogenerative conditions, its impairment perhaps contributing to the mis-accumulation of soluble proteins." [This may also be involved in traumatic brain injury, Parkinson's disease, Alzheimer's disease, and glial cell interactions that may affect cognitive dysfunctions in FM. DJS]

Illes JD, Maola CJ. 2012. Chiropractic management of low back pain in a patient with a transfemoral amputation. J Chiropr Med. 11(3):179-185. "Chiropractic management included manipulative therapy to the lumbar spine and pelvis, trigger point therapy of hypertonic musculature, and strengthening of pelvic musculature. In addition, the patient's prosthetist shortened her new prosthetic device. After 18 treatments, LBP (low back pain) severity was resolved (0/10); and there was an overall improvement with gait biomechanics….This case illustrates the importance of considering leg length inequality in patients with amputations as a possible cause of lower back pain, and that proper management may include adjusting the length of the prosthetic device and strengthening of the hip flexors and abductors, in addition to trigger point therapy and chiropractic manipulation."

Ilter L, Dilek B, Batmaz I et al. 2014. Efficacy of pulsed and continuous therapeutic ultrasound in myofascial pain syndrome: A randomized controlled study. Am J Phys Med Rehabil. Oct 8. [Epub ahead of print] "This study aimed to compare continuous and pulsed ultrasound therapy with sham ultrasound in terms of pain, severity of muscle spasm, function, depression, and quality of life in patients with myofascial pain syndrome….Continuous ultrasound therapy is more efficient in reducing pain at rest for myofascial pain syndrome patients than is sham or pulsed ultrasound therapy."

Im SH, Han EY. 2013. Improvement in anxiety and pain after whole body whirlpool hydrotherapy among patients with myofascial pain syndrome. Ann Rehabil Med. 37(4):534-540. This study found whirlpool therapy to be more effective than conventional hydrocollator packs for the treatment of myofascial pain.

Imamura M, Imamura ST, Targino RA et al. 2016. Paraspinous lidocaine injection for chronic nonspecific low back pain: A randomized controlled clinical trial. J Pain. [Jan 29 Epub ahead of print.] "In this large, sham-controlled, randomized trial, we examined the efficacy of the combination of standard treatment and paraspinous lidocaine injection compared with standard therapy alone in chronic low back pain…. There were significant changes in pain threshold immediately after treatment, supporting the effects of this intervention in reducing central sensitization. Paraspinous lidocaine injection therapy is not associated with a higher risk of adverse effects compared with conventional treatment and sham injection. Its effects on hyperalgesia might correlate with changes in central sensitization."

Imamura M, Targino RA, Hsing WT et al. 2014. Concentration of cytokines in patients with osteoarthritis of the knee and fibromyalgia. Clin Interv Aging. 9:939-944. "Patients with knee osteoarthritis and fibromyalgia with the same duration and intensity of pain demonstrate similar concentrations of cytokines. Aging may play a role in cytokine profile, a finding not so extensively addressed in the literature and one that should be further investigated."

Imamura, S.T., T.Y. Lin, M.J. Yriyrits, S.S. Fischer, R.J. Azze, L. A. Rosgano and R. Mahar. 1997. The importance of myofascial pain syndrome in reflex sympathetic dystrophy. Phys Med Rehab Clinics of North Am 8:207-211.

Imbierowicz K., Egle U.T. 2003.  Childhood adversities in patients with fibromyalgia and somatoform pain disorder.  Eur J Pain 7(2):113-9.  This study in primary FMS found that “The FM patients show the highest score of childhood adversities.  In addition to sexual and physical maltreatment, the FM patients more frequently reported a poor emotional relationship with both parents, a lack of physical affection, experiences of the parent’s physical quarrels, as well as alcohol or other problems of addiction in the mother, separation, and a poor financial situation before the age of 7.”

Inal S, Inal EE, Okyay GU et al. 2014. Fibromyalgia and nondipper circadian blood pressure variability. Clin Rheumatol. 20(8):422-426. "Ambulatory measurements showed significantly higher diastolic BP values in patients with FM for both average of 24-hour recordings. Patients with FM had significantly lower systolic…and diastolic dipping ratios…. The number of nondippers in the FM group was significantly higher than that of controls for both systolic…. and diastolic BP measurements…. Patients with FM were 3.68 times more likely to be systolic nondipper and 2.69 times more likely to be diastolic nondipper….We have demonstrated a significant relationship between FM and nondipping BP pattern, and we suggest that nondipping profile, which has been closely associated with cardiovascular morbidity, may appear as an additional risk factor in patients with FM."

Inanir A, Karakus N, Ates O. 2014. Clinical symptoms in fibromyalgia are associated to catechol-O-methyltransferase (COMT) gene Val158Met polymorphism. Xenobiotica. [Apr 24 Epub ahead of print.] "Fibromyalgia syndrome (FMS) is a common chronic widespread pain syndrome mainly affecting women. The aim of this study was to explore the frequency and clinical significance of catechol-O-methyltransferase (COMT) gene Val158Met polymorphism in a large cohort of Turkish patients with FMS. 2. The study included 379 FMS patients and 290 controls….The results of this study suggested that COMT gene Val158Met polymorphism is positively associated with FMS and play a relevant role in the clinical symptoms of the disease."

Inanir A, Yigit S, Tekcan A. 2015. Angiotensin converting enzyme and methylenetetrahydrofolate reductase gene variations in fibromyalgia syndrome. Gene. [Mar 28 Epub ahead of print.] "Our findings showed that there are associations of ACE I/D polymorphism with susceptibility of a person for development of fibromyalgia syndrome. Also, it is determined an association between MTHFR C677T polymorphism and feeling of stiffness and dry eye which are among the clinical characteristics of FM. Our study is the first report of ACE I/D and MTHFR C677T polymorphisms in fibromyalgia syndrome."

Ingber RS. 2000.  Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments.  Arch Phys Med Rehabil. 81(5):679-682.  “Conservative care of the athlete with shoulder impingement includes activity modification, application of ice, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid injections, and physiotherapy.  This case report describes the clinical treatment and outcome of three patients with shoulder impingement syndrome who did not respond to traditional treatment.  Two of the three were previously referred for arthroscopic surgery.  All three were treated with subscapularis trigger point dry needling and therapeutic stretching.  They responded to treatment and had returned to painless function at follow-up 2 years later.”

Ingber, R. S.  1989.  Iliopsoas myofascial dysfunction: a treatable cause of “failed” low back syndrome.  Arch Phys Med Rehabil 70(5):382-6.  

Ingman T, Nieminen T, Hurmerinta K. 2004.  Cephalometric comparison of pharyngeal changes in subjects with upper airway resistance syndrome or obstructive sleep apnoea in upright and supine positions.  Eur J Orthod 26(3):321-326.  “The present results suggest that OSA patients are prone to significant narrowing of their oropharyngeal, but not of their naso- or hypopharyngeal, airways in the supine position.  Thus, treatment of OSA and UARS patients should mainly be aimed at preventing further oropharyngeal airway narrowing as a result of supine-dependent sleep.”

Inoue K, Tsuda M, Koizumi S. 2004.  Chronic pain and microglia: the role of ATP.  Novartis Found Symp. 261:55-64.

Iodice P, Lessiani G, Franzone G et al. 2016. Efficacy of pulsed low-intensity electric neuromuscular stimulation in reducing pain and disability in patients with myofascial syndrome. J Biol Regul Homeost Agents. 30(2):615-620. "Myofascial pain syndrome (MPS) is characterized by chronic pain in multiple myofascial trigger points and fascial constrictions. In recent years, the scientific literature has recognized the need to include the patient with MPS in a multidimensional rehabilitation project. At the moment, the most widely recognized therapeutic methods for the treatment of myofascial syndrome include the stretch and spray pressure massage. Microcurrent electric neuromuscular stimulation was proposed in pain management for its effects on normalizing bioelectricity of cells and for its sub-sensory application. In this study, we tested the efficacy of low-intensity pulsed electric neuromuscular stimulus (PENS) on pain in patients with MPS of cervical spine muscles.… Modulated low-intensity PENS is an innovative therapy permitting to act on the transmission of pain and on the restoration of tissue homeostasis. It seems to affect the transmission of pain through the stimulation of A-beta fibers. The above results show that low-intensity PENS can be considered as an effective treatment to reduce pain and disability in patients with MPS."

Irwin, M., J. McClintick, C. Costlow, M. Fortner, J. White and J. C. Gillin. 1996. Partial night sleep deprivation reduces natural killer and cellular immune responses in humans.  FASEB J10(5):643-653.

Irwin RS, Madison JM. 2000.  Anatomical diagnostic protocol in evaluating chronic cough with specific reference to gastroesophageal reflux disease.  Am J Med. 108 Suppl 4a:126S-130S.  “Gastroesophageal reflux disease (GERD), along with postnasal drip syndrome (PNDS) and asthma, is one of the three most common causes of chronic cough in all age groups.  When GERD is the cause of chronic cough, there may be no gastrointestinal (GI) symptoms up to 75% of the time, and, in these cases, the term ‘silent GERD’ is used.”

Isasi C, Colmenero I, Casco F et al. 2014. Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. Rheumatol Int. [Apr 12 Epub ahead of print.] "Fibromyalgia (FM) syndrome is a disabling clinical condition of unknown cause, and only symptomatic treatment with limited benefit is available. Gluten sensitivity that does not fulfill the diagnostic criteria for celiac disease (CD) is increasingly recognized as a frequent and treatable condition with a wide spectrum of manifestations that overlap with the manifestations of FM, including chronic musculoskeletal pain, asthenia, and irritable bowel syndrome. The aim of this report was to describe 20 selected patients with FM without CD who improved when placed on a gluten-free diet. An anti-transglutaminase assay, duodenal biopsy, and HLA typing were performed in all cases. CD was ruled out by negative anti-transglutaminase assay results and absence of villous atrophy in the duodenal biopsy. All patients had intraepithelial lymphocytosis without villous atrophy. Clinical response was defined as achieving at least one of the following scenarios: remission of FM pain criteria, return to work, return to normal life, or the discontinuation of opioids. The mean follow-up period was 16 months (range 5-31). This observation supports the hypothesis that non-celiac gluten sensitivity may be an underlying cause of FM syndrome." [The authors have found one common perpetuating factor for at least one subgroup of patients with FM. DJS]

Isasi C, Tejerina E, Moran LM. 2015. Non-celiac gluten sensitivity and rheumatologic diseases. Reumatol Clin. [May 5 Epub ahead of print.] [Article in English, Spanish] "Celiac disease is an autoimmune systemic disease having among its clinical manifestations frequent symptoms common to rheumatologic diseases such as musculoskeletal pain, asthenia, and cognitive fatigue. It is associated with other autoimmune diseases like Sjögren disease. It is a well-characterized disease with specific diagnostic tests. Non-celiac gluten sensitivity is an emerging entity with symptoms similar to celiac disease, but without specific diagnostic tests. The concept of non-celiac gluten sensitivity and its diagnostic problems are reviewed, and the hypothesis of its association with fibromyalgia, spondyloarthritis, and autoimmune conditions is proposed. Clinical observations supporting the hypothesis are described, highlighting the benefit of treating non-celiac gluten sensitivity." Free Article

Isomaa B. 2003.  A major health hazard: the metabolic syndrome.  Life Sci 73(19):2395-2411.  “The metabolic syndrome seems to result from a collision between susceptible ‘thrifty genes’ and a society characterized by an increased prevalence of obesity and a sedentary lifestyle.”  “The metabolic syndrome constitutes a major challenge for public health…since more than 40 million U.S. adults seem to be affected….  Lifestyle changes could have a profound influence on the syndrome and its development.”

Israel HA, Ward JD. Horrell B, et al. 2003.  Oral and maxillofacial surgery in patients with chronic orofacial pain.  J Oral Maxillofac Surg 61(6):662-7.  “Misdiagnosis and multiple failed treatments were common in these patients with chronic orofacial pain ..... surgical treatment was rarely indicated as a treatment for pain relief ..... and it exacerbated and perpetuated pain symptoms in some of them.”

Isomaa B. 2003. A major health hazard: the metabolic syndrome. Life Sci 73(19):2395-2411. “The metabolic syndrome seems to result from a collision between susceptible ‘thrifty genes’ and a society characterized by an increased prevalence of obesity and a sedentary lifestyle.” “The metabolic syndrome constitutes a major challenge for public health…since more than 40 million U.S. adults seem to be affected…. Lifestyle changes could have a profound influence on the syndrome and its development.”

Isu T, Kim K, Morimoto D et al. 2018. Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine. 15(1):25-32. "The superior and the middle cluneal nerves (SCN and MCN) are cutaneous nerves that are purely sensory. They dominate sensation in the lumbar area and the buttocks, and their entrapment around the iliac crest can elicit LBP." SCN reported nerve entrapment in LBP is up to 14%. SCN-E is reported to cause up to 84% leg symptoms and MCN-E to cause 82% leg symptoms in LBP patients. "In such patients, pain is exacerbated by lumbar movements, and the symptoms mimic radiculopathy due to lumbar disorder. As patients with failed back surgery or Parkinson disease also report LBP, the differential diagnosis must include those possibilities. The identification of the trigger point at the entrapment site and the disappearance of symptoms after nerve block are diagnostically important. LBP due to SCN-E or MCN-E can be treated less invasively by nerve block and neurolysis. Spinal surgeons treating patients with LBP should consider SCN-E or MCN-E."

Ita ME, Crosby ND, Bulka BA et al. 2016. Painful cervical facet joint injury is accompanied by changes in the number of excitatory and inhibitory synapses in the superficial dorsal horn that differentially relate to local tissue injury severity. Spine (Phila Pa 1976). [Oct 17 Epub ahead of print.] "This study (in rats) demonstrates a role for structural plasticity in both excitatory and inhibitory synapses in the maintenance of facet-mediated joint pain, and that altered inhibitory, but not excitatory, synapse density correlates to the severity of painful joint injury. Understanding the functional consequences of this spinal structural plasticity is critical to elucidate mechanisms of chronic joint pain."

Itoh K, Katsumi Y, Hirota S et al. 2006.  Effects of trigger point acupuncture on chronic low back pain in elderly patients – a sham-controlled randomized trial.  Acupunct Med. 24(1):5-12.  “These results suggest that trigger point acupuncture may have greater short term effects on low back pain in elderly patients than sham acupuncture.”

Itoh K, Katsumi Y, Kitakoji H. 2004. Trigger point acupuncture treatment of chronic low back pain in elderly patients—a blinded RCT. Acupunct Med. 22(4):170-177. Deep needling of trigger points may be more effective for low back pain in the elderly than either superficial TrP needling or standard acupuncture.

Itoh K, Okada K. 2007.  Influence of ovariectomy on development of delayed onset muscle soreness in female rates.  J Musculoskel Pain 15 (Supp 13):26 item 42.  [Myopain 2007 Poster]  “In the present study, the muscle pain thresholds were influenced by the estrus cycle in the intact control female rates.  The delay of development of muscular hyperalgesia was also detected in the OVX rats.  These results suggest that the change of estrogen content might be a possible influence on the sensitivity of nociceptive process.”  [This meshes well with other research that suggests that changes in estrogen may be involved in pain modulation. DJS]

Itoh K, Saito S, Sahara S et al. 2014. Randomized trial of trigger point acupuncture treatment for chronic shoulder pain: a preliminary study. J Acupunct Meridian Stud. 7(2):59-64. "We compared the effect of trigger point acupuncture (TrP), with that of sham (SH) acupuncture treatments, on pain and shoulder function in patients with chronic shoulder pain. The participants were 18 patients (15 women, 3 men; aged 42-65 years) with nonradiating shoulder pain for at least 6 months and normal neurological findings. The participants were randomized into two groups, each receiving five treatment sessions. The TrP group received treatment at trigger points for the muscle, while the other group received SH acupuncture treatment on the same muscle…. Compared with SH acupuncture therapy, TrP therapy appears more effective for chronic shoulder pain."

Itza F, Zarza D, Salinas JC et al. 2015. Turn-amplitude analysis as a diagnostic test for myofascial syndrome in patients with chronic pelvic pain. Pain Res Manag. 20(2):96-100. "Background: Myofascial pain syndrome of the pelvic floor (MPSPF) is a common disease in the context of chronic pelvic pain (CPP); however, there is currently no gold-standard test to diagnose it. Objective: To validate the turns-amplitude analysis (TAA) as a diagnostic test for MPSPF in patients with CPP. Methods:...The same operator conducted all tests. Electromyography of the TAA is based on the collection of motor unit potentials that measure the number of changes in the signal and the mean amplitude of the changes. The electromyogram transfers the data to a graphical point cloud, which enables the patient's results to be compared with the results of the healthy subjects. Results: In patients and control subjects, the sensitivity and specificity of the proposed diagnostic test showed a marked clinical significance: the sensitivity was 83%, and the specificity was 100%....Conclusion: TAA is a reliable diagnostic test to detect MPSPF. Further studies are needed to reproduce these results." Free PMC Article

Itza F, Zarza D, Salinas J et al. 2013. Anal stretching device for patients with chronic prostatitis and chronic pelvic pain syndrome. Arch Esp Urol. 66(2):201-205. [Article in English, Spanish]. "Chronic pelvic pain syndrome (CPPS) is a poorly understood and ill-treated condition. It is accompanied by the shortening and increase in tone of the pelvic floor muscles and is closely related to myofascial pain syndrome (MPS). This study aims to evaluate the utility of an anal stretching device (ASD) for improving the pain manifestations of chronic prostatitis (CP) and CPPS….ASD appears to be a safe and useful tool to treat the pain manifestations of CPPS without notable side effects." [One must address the cause of muscle shortening and increased tone; myofascial trigger points. DJS]

Itza F, Zarza D, Serra L et al. 2010. [Myofascial pain syndrome in the pelvic floor: a common urological condition]. Actas Urol Esp. 34(4):318-326. [Spanish] “It is the most common cause of pain in the pelvic floor and greatly affects quality of life of patients. Nowadays, we have diagnostic and therapeutic tools that allow us to treat this disabling syndrome with good results.” [What these authors say is true, but it is also true that these tools are not often used and that many patients with myofascial TrPs are undiagnosed, misdiagnosed and untreated.  This must change. DJS]

Iudici M, Irace R, Riccardi A et al. 2017. Longitudinal analysis of quality of life in patients with undifferentiated connective tissue diseases. Patient Relat Outcome Meas. 8:7-13. "UCTD (undifferentiated connective tissue diseases) patients perceive a worse QoL (Quality of Life), regardless of Raynaud's phenomenon. Fibromyalgia is one of the major contributors of physical QoL, whereas no factor influencing mental component has been identified. An improvement in QoL can be observed in less than half of patients over a 2-year follow-up. Larger studies are needed to identify factors influencing QoL and to define the role of pharmacological treatments." Free PMC Article

Iwama H, Akama Y. 2000.  The superiority of water-diluted 0.25% to neat 1% lidocaine for trigger-point injections in myofascial pain syndrome: a prospective, randomized, double-blinded trial.  Anesth Analg. 91(2):408-409.  “Trigger-point injection with a mixture of commercially available 1% lidocaine in sterile distilled water at a ratio of 1:3 compared with 1% lidocaine alone resulted in better efficacy and less injection pain.  This simple procedure may be suitable for treatments of a wide range of myofascial pain syndromes.”

Iwama H, Ohmori S, Kaneko T et al. 2001.  Water-diluted local anesthetic for trigger-point injection in chronic myofascial pain syndrome: evaluation of types of local anesthetic and concentrations in water.  Reg Anesth Pain Med. 26(4):333-336.  “The suitable type of local anesthetic may be lidocaine or mepivacaine, and the most effective water-diluted concentration is considered to be 0.2% to 0.25%.

Izumi M, Petersen KK, Arendt-Nielsen L et al. 2014. Pain referral and regional deep tissue hyperalgesia in experimental human hip pain models. Pain. 155(4):792-800. Hip pain and hyperalgesia was produced experimentally in health individuals by injecting them with hypertonic saline solution in the gluteus medius tendon, adductor longus tendon, or gluteus medius muscle. [This experiment basically created referred pain patterns and hyperalgesia, such as occurs with myofascial trigger points in these muscles and tendons. DJS]

Jackman RP, Purvis JM, Mallett BS. 2008. Chronic nonmalignant pain in primary care. Am Fam Physician. 78(10):1155-1162.

Jackson T, Thomas S, Stabile V et al. 2016. Chronic pain without clear etiology in low- and middle-income countries: A narrative review. Anesth Analg. 122(6):2028-2039. "Women, elderly patients, and workers, especially in low-income and low-education subgroups, were more likely to have pain in multiple sites, mood disorders, and disabilities. In high-income countries, multisite pain without etiology, female gender, and association with mood disturbance and disability may be suggestive of a central sensitization syndrome (CSS). Because each type of prevalent chronic pain without known etiology reviewed had similar associations in LMICs, strategies for assessment and treatment of chronic pain worldwide should consider the possibility of prevalent CSS. Recognition is especially critical in resource-poor areas, because treatment of CSS is vastly different than localized chronic pain.

Jacob L, Jacob T, Jacob B. 2007.  Escitaloproan for fibromyalgia and multiple chemical sensitivity syndrome: Tolerable efficacy.  J Musculoskel Pain 15(Suppl 13):50. item 87.  Escitalopran (Lexapro) seems to help FM pain even if patients don't have MCS, and it appears to be well tolerated and have few side-effects. 

Jacobsen, S. and B. Danneskiold-Samsoe. 1992. Dynamic muscular endurance in primary fibromyalgia compared with chronic myofascial pain syndrome. Arch Phys Med Rehab 73(2):170-173.

Jacobson PL, Mann JD. 2003. Evolving role of the neurologist in the diagnosis and treatment of chronic noncancer pain. Mayo Clin Proc 78(1):80-84. “The neurologist has become increasingly involved in the multidisciplinary treatment of patients with chronic noncancer pain. Informed regulatory agencies and professional organizations such as the American Academy of Neurology recognize the undertreatment of patients with CNP and provide clear recommendations to help neurologists in the ethical and effective treatment of patients with pain. Improved education of neurologists, other health care professionals, patients, and the media about evolving standards of pain care and therapy will produce a more supportive environment for the compassionate and ethical treatment of patients with CNP."

Jacobson PL, Mann JD. 2003.  Evolving role of the neurologist in the diagnosis and treatment of chronic noncancer pain.  Mayo Clin Proc. 78(1):80-84.  “Informed regulatory agencies and professional organizations such as the American Academy of Neurology recognize the undertreatment of patients with CNP and provide clear recommendations to help neurologists in the ethical and effective treatment of patients with pain.  Improved education of neurologists, other health care professionals, patients, and the media about evolving standards of pain care and therapy will produce a more supportive environment for the compassionate and ethical treatment of patients with CNP.”

Jacobson SA, Simpson RG, Lubahn C et al. 2014. Characterization of fibromyalgia symptoms in patients 55-95 years old: a longitudinal study showing symptom persistence with suboptimal treatment. Aging Clin Exp Res. [May 25 Epub ahead of print.] "In this cohort of elders with suboptimally treated FM, substantial persistence of symptoms was seen over time. In general, recommended treatments were either not used or not tolerated…. Age-appropriate treatments as well as education of primary care providers are needed to improve treatment of FM in the older population."

Jaeger B. 2013. Myofascial trigger point pain. Alpha Omegan. 106(1-2):14-22. "Myofascial trigger point pain is an extremely prevalent cause of persistent pain disorders in all parts of the body, not just the head, neck, and face. Features include deep aching pain in any structure, referred from focally tender points in taut bands of skeletal muscle (the trigger points). Diagnosis depends on accurate palpation with 2-4 kg/cm2 of pressure for 10 to 20 seconds over the suspected trigger point to allow the referred pain pattern to develop. In the head and neck region, cervical muscle trigger points (key trigger points) often incite and perpetuate trigger points (satellite trigger points) and referred pain from masticatory muscles. Management requires identification and control of as many perpetuating factors as possible (posture, body mechanics, psychological stress or depression, poor sleep or nutrition). Trigger point therapies such as spray and stretch or trigger point injections are best used as adjunctive therapy."

Jaeger B. 1989. Are “cervicogenic” headaches due to myofascial pain and cervical spine dysfunction?  Cephalalgia 9(3):157-164.  “Eleven patients with cervicogenic headaches were systematically examined for myofascial trigger points and cervical spine dysfunction.  All patients had at least three myofascial trigger points on the symptomatic side.  In eight of these patients, trigger point palpation clearly reproduced their headache.  There were 70 myofascial trigger points (35 ‘very tender’, 35 ‘tender’) and 17 non-myofascial tender points on the symptomatic side, compared to 22 myofascial trigger points (one ‘very tender’, 21 ‘tender’) and 19 non-myofascial tender points on the asymptomatic side.”  “Treated patients reported a significant decrease in the frequency and intensity of their headaches during a median two-year follow-up.  It is concluded that myofascial trigger points may be an important pain producing mechanism in cervicogenic headache and that segmental cervical dysfunction is a common feature in such patients.  Conservative, non-surgical treatment appears to be effective in reducing the frequency and intensity of cervicogenic headache.  These data suggest that surgical approaches should be reserved only for those patients who fail conservative therapy.”  [This study did not include non-cervical TrPs that refer pain to the head.  If extrinsic eye TrPs, posterior tongue TrPs, upper trapezius TrPs and the many other TrP sites that do exactly that were well known and considered, the need for surgery, and the rate of “failed” surgery, would drop even more dramatically.  DJS]

Jaeger B, Reeves JL. 1986.  Quantification of changes in myofascial trigger point sensitivity with the pressure algometer following passive stretch.  Pain. 27(2):203-210.  “In order to determine the relationship between trigger point sensitivity and the referred symptoms of myofascial pain, VAS ratings of referred pain intensity and pressure algometer measures of myofascial trigger point sensitivity were taken pre- and post-treatment of the muscle containing the trigger point with passive stretch.  The results in 20 subjects, experiencing unilateral or bilateral myofascial head and neck pain, showed that myofascial trigger point sensitivity decreases in response to passive stretch as assessed by the pressure algometer, and that trigger point sensitivity and intensity of referred pain are related.”

Jafari M, Bahrpeyma F, Mokhtari-Dizaji M et al. 2018. Novel method to measure active myofascial trigger point stiffness using ultrasound imaging. J Bodyw Mov Ther. 22(2):374-378. This study from Iran "indicated that MTrPs were stiffer than normal parts of the muscle. This study presents a new method for the quantitative measurement of the elastic modulus of MTrP, thereby distinguishing MTrPs from normal adjacent muscular tissue, with more simplicity and lower cost, compared to other ultrasound methods."

Jafari M, Bahrpeyma F, Togha M. 2017. Effect of ischemic compression for cervicogenic headache and elastic behavior of active trigger point in the sternocleidomastoid muscle using ultrasound imaging. J Bodyw Mov Ther. 21(4):933-939 "The improvements in outcome measures suggest that ischemic compression may be effective in subjects with a cervicogenic headache associated with a myofascial trigger point in the sternocleidomastoid muscle. Data suggests that biomechanical properties of MTrP and severity of headache symptoms are not directly linked, and other mechanisms could be more influential in contributing to symptoms." [This indicates that central sensitization and other factors may have a major role in level of pain from SCM TrPs. DJS]

Jafri MS. 2014. Mechanisms of myofascial pain. Int Sch Res Notices. 2014;2014. pii: 523924. "Myofascial pain syndrome is an important health problem. It affects a majority of the general population, impairs mobility, causes pain, and reduces the overall sense of well-being. Underlying this syndrome is the existence of painful taut bands of muscle that contain discrete, hypersensitive foci called myofascial trigger points. In spite of the significant impact on public health, a clear mechanistic understanding of the disorder does not exist. This is likely due to the complex nature of the disorder which involves the integration of cellular signaling, excitation-contraction coupling, neuromuscular inputs, local circulation, and energy metabolism. The difficulties are further exacerbated by the lack of an animal model for myofascial pain to test mechanistic hypothesis. In this review, current theories for myofascial pain are presented and their relative strengths and weaknesses are discussed. Based on new findings linking mechanoactivation of reactive oxygen species signaling to destabilized calcium signaling, we put forth a novel mechanistic hypothesis for the initiation and maintenance of myofascial trigger points. It is hoped that this lays a new foundation for understanding myofascial pain syndrome and how current therapies work, and gives key insights that will lead to the improvement of therapies for its treatment."

Jain AK, Carruthers BM, van de Sande MI, Barron SR, Donaldson CCS, Dunne JV, Gingrich E, Heffez DS, Leung FYK, Malone DG, Romano TJ, Russell IJ, Saul D, Seibel DG.  2003.  Fibromyalgia syndrome: Canadian clinical working case definition, diagnostic and treatment protocols – a consensus document.  J Musculoskel Pain 11(4):3-107.

Jalil NA, Prateepavanich P, Chaudakshetrin P. 2010. Atypical chest pain from myofascial pain syndrome of the subscapularis muscle. J Musculoskel Pain 18(2):173-179. This is a first-time report of subscapularis TrPs causing chest pain in two case reports. Both patients had restricted range of motion demonstrated by the Mouth Wraparound Test. Care providers should be aware of this presentation, in addition to the common subscapularis frozen shoulder and associated referral pain.

Jamison, R. N.  1996.  Comprehensive pretreatment and outcome assessment for chronic opioid therapy in nonmalignant pain.  J Pain Symptom Manage 11(4):231-241.  

Jamison, R. N., K. O. Anderson and M. A. Slater.  1995.  Weather changes and pain: perceived influence of local climate on pain complaint in chronic pain patients.  Pain 61(2):309-315.

Janakiraman R, Hamilton L, Wan A. 2016. Unravelling the efficacy of antidepressants as analgesics. Aust Fam Physician. 45(3):113-117. "Chronic pain is a large and growing public health concern in Australia. Chronic pain is generally associated with physical, psychological, social and cultural risk factors…. Knowledge of psychopharmacology is important in the management of chronic pain. The majority of patients with chronic pain have comorbid psychiatric conditions ranging from mild anxiety, depression and adjustment problems, to severe delusional and psychotic disorders. Depression and anxiety are known to enhance the perception of pain. Not all antidepressants have independent analgesic properties. There is now a convincing body of controlled data, as well as extensive longstanding clinical experience, supporting tricyclic antidepressants (TCAs) as analgesics independently of their antidepressant actions." Free Article

Janal MN, Ciccone DS, Natelson BH. 2006.  Sub-typing CFS patients on the basis of ‘minor’ symptoms.  Biol Psychol.  [Feb 9 Epub ahead of print]  “In 161 women meeting 1994 criteria for CFS, principal components analysis of the ten ‘minor’ symptoms of CFS produced three factors interpreted to indicate musculoskeletal, infectious and neurological subtypes.  Extreme scores on one or more of these factors characterized about 2/3 of the sample.”  “Results suggest that subtypes of CFS may be identified from reports of the minor diagnostic symptoms, and that these subtypes demonstrate construct validity.”

Janal MN, Raphael KG, Cook DB et al. 2016. Thermal temporal summation and decay of after-sensations in temporomandibular myofascial pain patients with and without comorbid fibromyalgia. J Pain Res. 9:641-652. "As previous research has shown that fibromyalgia (FM) is diagnosed in (about) 20% of TMD patients, Aim 1 determined whether central sensitization is found preferentially in myofascial TMD cases that have orofacial pain as a regional manifestation of FM. Aim 2 determined if the report of after-sensations (AS) following TS varied depending on whether repeated stimuli were rated as increasingly painful…. One hundred sixty-eight women, 43 controls, 100 myofascial TMD-only cases, and 25 myofascial TMD + FM cases, were compared on thermal warmth and pain thresholds, thermal TS, and decay of thermal AS. All cases met Research Diagnostic Criteria for TMD; comorbid cases also met the 1990 American College of Rheumatology criteria for FM." In this study, pain thresholds and temporal summation was similar in all groups, but after TS (temporal summation of second pain, or TSSP) was reached, at about 60%, there was significant after pain sensations in the TMJD group, and they decayed more slowly than the control group. "In this case-control study, all myofascial TMD cases were characterized by a similar delay in the decay of AS. Thus, this indicator of central sensitization failed to suggest different pain maintenance factors in myofascial TMD cases with and without FM." Free Article [This paper did not mention trigger points (or their criteria), and most of the authors are dentists or psychologists and are using the term "myofascial pain" to mean any jaw pain or TMJD. One must take care to view the research and the conclusions in that light. If these authors were to learn about chronic myofascial pain and dysfunction due to trigger points, and include specific criteria for them, as well as specific trigger pointed muscles affecting the TMJD, their research would be more valuable, and they might be able to provide more relief to their patients. DJS]

Janda AM, As-Sanie S, Tsodikov A et al. 2015. Fibromyalgia Survey Criteria Is Associated with Increased Postoperative Opioid Consumption in Women Undergoing Hysterectomy. Anesthesiology. [Mar 12 Epub ahead of print.] "As was previously demonstrated in a total knee and hip arthroplasty cohort, this study demonstrated that increased fibromyalgia survey scores were predictive of postoperative opioid consumption in the posthysterectomy surgical population during their hospital stay. By demonstrating the generalizability in a second surgical cohort, these data suggest that patients with fibromyalgia-like characteristics may require a tailored perioperative analgesic regimen." [In summary, patients with amplified pain (FM) require more pain medication. This surprises? DJS]

Jang JY, Kwon JS, Lee DH et al. 2016. Clinical signs and subjective symptoms of temporomandibular disorders in instrumentalists. Yonsei Med J. 57(6):1500-1507. "A total of 739 musicians from a diverse range of instrument groups completed a TMD questionnaire. Among those who reported at least one symptom of TMD, 71 volunteers underwent clinical examinations and radiography for diagnosis…. Overall, 453 participants (61.3%) reported having one or more symptoms of TMD. The most frequently reported symptom was a clicking or popping sound, followed by temporomandibular joint (TMJ) pain, muscle pain, crepitus, and mouth opening limitations. Compared with lower-string instrumentalists, a clicking or popping sound was about 1.8 and 2 times more frequent in woodwind and brass instrumentalists, respectively. TMJ pain was about 3.2, 2.8, and 3.2 times more frequent in upper-string, woodwind, and brass instrumentalists, respectively. Muscle pain was about 1.5 times more frequent in instrumentalists with an elevated arm position than in those with a neutral arm position. The most frequent diagnosis was myalgia or myofascial pain (MFP), followed by disc displacement with reduction. Myalgia or MFP was 4.6 times more frequent in those practicing for no less than 3.5 hours daily than in those practicing for less than 3.5 hours….The results indicate that playing instruments can play a contributory role in the development of TMD". Free Article on web

Janis JE, Dhanik A, Howard JH. 2011. Validation of the peripheral trigger point theory of migraine headaches: single-surgeon experience using botulinum toxin and surgical decompression. Plast Reconstr Surg. 128(1):123-131. [Although less invasive treatments are often successful, this article is of interest in that it confirms a nasal TrP. DJS]

Janis JE, Hatef DA, Ducic I et al. 2010. Anatomy of the auriculotemporal nerve: variations in its relationship to the superficial temporal artery and implications for the treatment of migraine headaches. Plast Reconstr Surg. 125(5):1422-1428. “In an effort to better understand potential etiologies for failure of treatment, an investigation was performed to determine whether or not vascular-mediated peripheral trigger points exist that have heretofore been undescribed that may be contributing to persistent symptomatology. One such potential trigger point is the superficial temporal artery’s interaction with the auriculotemporal nerve.” “The auriculotemporal nerve and superficial temporal artery run together in the superficial soft tissue in the preauricular and temple regions. A contiguous relationship between the two was found in 17 hemiheads (34.0 percent). ”These variations may serve as an anatomical explanation for this point as a source of migraine headaches in some patients.”

Janis JE, Hatef DA, Ducic I et al. 2010. Anatomy of the auriculotemporal nerve: variations in its relationship to the superficial temporal artery and implications for the treatment of migraine headaches. Plast Reconstructr Surg 125(5):1422-1428. This study of 25 cadaver heads found a 34.0% occurrence of a contiguous relationship between the ariculotemporal nerve and the superficial temporal artery that may be a potential vascular-mediated TrP and possible migraine instigator.

Janis JE, Hatef DA, Reece EM et al. 2010. Neurovascular compression of the greater occipital nerve: implications for migraine headaches. Plast Reconstr Surg. 126(6):1996-2001. [The greater occipital nerve can be entrapped by TrPs in the semispinalis capitis muscle. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual Vol I ed 2 page 126.]

Jankovic D, van Zundert A. 2006.  The frozen shoulder syndrome.  Description of a new technique and five case reports using the subscapular nerve block and subscapularis trigger point infiltration.  Acta Anaesthesiol Belg. 57(2):137-143.

Janssens KA, Zijlema WL, Joustra ML et al. 2015. Mood and anxiety disorders in chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome: Results from the LifeLines Cohort Study. Psychosom Med. [Mar 12 Epub ahead of print.] "Mood and anxiety disorders are more prevalent in individuals with FSSs, and particularly CFS, than in individuals without FSSs. However, most individuals with FSSs do not have mood or anxiety disorders."

Janssens L, Brumagne S, McConnell AK. 2013. Proprioceptive changes impair balance control in individuals with chronic obstructive pulmonary disease. PLoS One. 8(3):e57949. "Individuals with COPD, especially those with inspiratory muscle weakness, increased their reliance on ankle muscle proprioceptive signals and decreased their reliance on back muscle proprioceptive signals during balance control, resulting in a decreased postural stability compared to healthy controls. These proprioceptive changes may be due to an impaired postural contribution of the inspiratory muscles to trunk stability. Further research is required to determine whether interventions such as proprioceptive training and inspiratory muscle training improve postural balance and reduce the fall risk in individuals with COPD."

Jaracz J, Rybakowski J. 2005.  [Depression and pain: novel clinical, neurobiological and psychopharmacological data]  Psychiatr Pol. 39(5):937-950.  [Polish]  “In the pathogenesis of both depression and pain symptoms, an important role has been attributed to disturbances of serotonergic and noradrenergic neurotransmission as well as to neuropeptides such as opioids and substance P.  In mood regulation as well as in the perception and emotional dimension of pain stimuli, such brain structures as the amygdala, anterior cingulate cortex and prefrontal cortex are of main significance.  The action of antidepressant drugs results in a normalization of the activity of those neurotransmitter systems an brain structures.  It was found that dual action antidepressants (i.e., influencing both serotonergic and noradrenergic system) such as tricyclic antidepressants and new generation drugs (venlafaxine, milnacipram, duloxetine, mirtazapine) exert a stronger antidepressant effect and possess a broader therapeutic spectrum, including also an effect on pain symptoms.” 

Jaroshevskyi OA, Payenok OS, Logvinenko AV. 2017. Evaluation of the effectiveness of multimodal approach to the management of cervical vertigo. Wiad Lek. 70(3 pt 2):571-573. In this study from the Ukraine, "109 patients aged from 18 to 45 with vertigo together with myofascial pain syndrome of neck and shoulder area were examined… The multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability."

Jarrell J. 2011. Endometriosis and Abdominal Myofascial Pain in Adults and Adolescents. Curr Pain Headache Rep. [Jul 14 Epub ahead of print]. "Endometriosis and myofascial pain are common disorders with significant impact on quality of life. Increasingly, these conditions are being recognized as highly interconnected through processes that have been described for more than a century. [Emphasis DJS] This review is directed to this interconnection through a description of the relationships of endometriosis to proposed mechanisms of pain and chronic pain physiology; the clinical assessment of myofascial representations of this pain; and an approach to the management of these interconnected disorders."

Jarrell J. 2010. Myofascial pain in the adolescent. Curr Opin Obstet Gynecol. 22(5):393-8. "Pain associated with myofascial dysfunction is common in the adolescent female. Pain in this group of women has been shown to extend into adulthood. Although there has been attention directed to the management of endometriosis through laparoscopic surgical approaches, these are seen as limiting. Myofascial dysfunction is now regarded as an important factor in the evaluation of adolescent pain. One of the most important approaches to the reduction of severe pain in the adolescent is the complete menstrual suppression through use of continuous oral contraceptives or contraceptive rings. Operative laparoscopy has been heavily utilized but there are increasing concerns about the overutilization of this procedure.... Alternative approaches to myofascial pain include multidisciplinary care with a rehabilitative perspective." [It is vital that care providers learn prompt diagnosis and treatment of myofascial trigger points. Procedures such as laparoscopy can both activate and perpetuate TrPs. DJS]

Jarrell J 2009. Demonstration of cutaneous allodynia in association with chronic pelvic pain. J Vis Exp 23(28).pii 1232. doi 10.3791/1232. This shows how episodic pelvic pain from painful menstrual periods, or chronic pain from endometriosis, can result in chronic pelvic pain with central sensitization hallmarks such as allodynia (pain from normally non-painful stimuli). Abdominal wall tenderness and dyspareunia (pain with intercourse) are common at that stage. By the time signs of a central sensitization state have occurred, this pain can persist after medical or surgical treatment of the initial cause as part of a viscero-somatic reflex. At this state, surgical intervention is not usually necessary, as the presence of abdominal wall and other area TrPs may be maintaining this heightened central pain state.

Jarrell J. 2004.  Myofascial dysfunction in the pelvis.  Curr Pain Headache Rep 8:452-456.  Between 25% and 40% of all laparoscopy for pelvic pain finds no cause.  Myofascial pain due to TrPs may be a significant and unrecognized cause of much pelvic pain.   

Jarrell J, Giambarardino MA, Robert M et al. 2011. Bedside testing for chronic pelvic pain: discriminating visceral from somatic pain. Pain Res Treat 2011:692102. "Tests of cutaneous allodynia, myofascial trigger points, and reduced pain thresholds are easily applied and well tolerated. The tests for cutaneous allodynia appear to have the greatest likelihood of identifying a visceral source of pain compared to somatic sources of pain."

Jarrell JF, Vilos GA, Allaire C et al. 2005.  Consensus guidelines for the management of chronic pelvic pain.  J Obstet Gynaecol Can. 27(8):781-826.  Myofascial pain must be taken into account when looking for possible causes of chronic pelvic pain.

Jason LA, McManimen S, Sunnquist M et al. 2017. Examining those meeting IOM Criteria versus IOM plus fibromyalgia. Neurology (ECronicon). 5(1):19-28. "The Institute of Medicine (IOM) recently developed clinical criteria for chronic fatigue syndrome (CFS). There might be additional criteria that could select a more homogenous and impaired group of patients, particularly those with pain. The current study focused on criteria which involved meeting the four IOM criteria, excluding medical and psychiatric co-morbidities, along with having fibromyalgia (FM). Findings indicated that those meeting the IOM clinical criteria plus FM were more impaired on a wide variety of symptoms and functional areas than those meeting on the IOM criteria or those with just 6 months of fatigue." Free Article

Jason LA, Taylor RR, Kennedy CL. 2000.  Chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivities in a community-based sample of persons with chronic fatigue syndrome-like symptoms.  Psychosom Med. 62(5):655-663.  “People with CFS, MCS or FM endure significant disability in terms of physical, occupational and social functioning, and those with more than one of these diagnoses also report greater severity of physical and mental fatigue.”

Jaussent I, Morin CM, Ivers H et al. 2017. Incidence, worsening and risk factors of daytime sleepiness in a population-based 5-year longitudinal study. Sci Rep. 7(1):1372. This study found that "persistent sleepiness was associated with chronic medical diseases thus highlighting a homogeneous group at risk requiring a dedicated management." Free Article

Jayaseelan DJ, Moats, N, Ricardo CR. 2013. Rehabilitation of proximal hamstring tendinopathy utilizing eccentric traoning, lumbopelvic stabilization, and trigger point dry needling: 2 case reports. J Orthop Sports Phys Ther. Nov 21 [Epub ahead of print]. Two runners with proximal hamstring tendinopathy were treated with a specific exercise program and dry needling. Both patients were seen for 8-9 visits over 8-10 weeks, and returned to sitting and running without symptoms.

Jayawardena ADL, Chandra R. 2018. Headaches and facial pain in rhinology. Am J Rhinol Allergy. 32(1):12-15. "'Sinus headache' is a common chief complaint that often leads patients to an otolaryngologist's office. Because facial pain may or may not be sinogenic in origin, the otolaryngologist should be equipped to evaluate and treat or to appropriately refer these patients. Analysis of current data indicates that the majority of patients who present with sinus headaches actually have migraines. Furthermore, the downstream effect of the cytokine cascade initiated in migraine physiology can cause rhinologic symptoms, including rhinorrhea, congestion, and lacrimation, which may also confound diagnosis. Other causes of sinus headache include the following: cluster headaches, Sluder neuralgia, trigeminal neuralgia, myofascial trigger point pain (tension headaches, temporomandibular joint dysfunction), and contact point headaches. The diagnostic dilemma for an otolaryngologist occurs when a patient has facial pain and symptoms that may indicate chronic rhinosinusitis but with nondiagnostic endoscopy. Traditionally, these patients have been primarily managed with empiric antibiotics. An alternative strategy is to first screen these patients with an upfront computed tomography. This algorithm may ultimately decrease cost; avert unnecessary antibiotics prescriptions; and prompt more timely referrals to other, more appropriate, disciplines, such as neurology, dentistry, and/or pain management specialists."

Jeal, W. and P. Benfield. 1997.  Transdermal fentanyl.  A review of its pharmacological properties and therapeutic efficacy in pain control.  Drugs 53(1):109-138.

Jeffery DD, Bulathsinhala L, Kroc M et al. 2014. Prevalence, health care utilization, and costs of fibromyalgia, irritable bowel, and chronic fatigue syndromes in the military health system, 2006-2010. Mil Med 179(9):1021-1029. "Although cause and effect cannot be established, the advent of federally approved drugs for FMS in concert with pharmaceutical industry marketing of these drugs coincide with the observed changes in prevalence, health care utilization, and costs of FMS relative to IBS and CFS."

Jenewein J, Moergeli H, Sprott H et al. 2013. Fear-learning deficits in subjects with fibromyalgia syndrome? Eur J Pain. [Mar 7 Epub ahead of print]. "Contingency learning deficits represent a potentially promising and specific, but largely unstudied, psychopathological factor in FMS. Deficits in contingency learning may increase anxiety and, consequently, pain sensation. These findings have the potential to contribute to the development of novel therapeutic approaches for FMS."

Jennings, JR, Muldoon MF, Hall M et al. 2007.  Self-reported sleep quality is associated with the metabolic syndrome.  Sleep. 30(2):219-223.

Jensen, K. A., S. K. Christensen, E. M. Nielsen, L. K. Bunemann, K. Therkelsen and F. Knudsen.1997. [Cerebral blood flow and indomethacin.  The effect of different doses administered as continuous intravenous infusions or as suppositories in healthy adults]. Ugeskr Laeger 159(27):4257-4260 [Danish].

Jensen KB, Loitoile R, Kosek E et al. 2012. Patients with Fibromyalgia Display less Functional Connectivity in the Brain's Pain Inhibitory Network. Mol Pain. 8(1):32. "Patients with FM displayed less connectivity within the brain's pain inhibitory network during calibrated pressure pain, compared to healthy controls. The present study provides brain-imaging evidence on how brain regions involved in homeostatic control of pain are less connected in FM patients. It is possible that the dysfunction of the descending pain modulatory network plays an important role in maintenance of FM pain and our results may translate into clinical implications by using the functional connectivity of the pain modulatory network as an objective measure of pain dysregulation."

Jensen KB, Sriniasan P, Spaeth R et al. 2013. Overlapping structural and functional brain changes in patients with long-term exposure to fibromyalgia. Arthritis Rheum. [Aug 27 Epub ahead of print]. "FM patients displayed a distinct overlap between decreased cortical thickness, brain volumes and measures of functional regional coherence in the rostral anterior cingulate cortex. The morphometric changes were more pronounced with longer exposure to FM pain. In addition, we found associations between structural and functional changes in the mesolimbic areas of the brain and comorbid depressive symptoms in FM patients. Conclusion: The combined integration of structural and functional measures allowed for a unique characterization of the impact of FM pain on the brain. Our data may lead to the identification of early structural and functional brain alterations in response to pain, which could be used to develop markers to predict the development of FM and other pain disorders."

Jensen MP, Nielson WR, Turner JA et al. 2004.  Changes in readiness to self-manage pain are associated with improvement in multidisciplinary pain treatment and pain coping.  Pain 111(1-2):84-95.

Jeon JH, Jung YJ, Lee JY et al. 2012. The effect of extracorporeal shock wave therapy on myofascial pain syndrome. Ann Rehabil Med. 36(5):665-674. "The ESWT (extracorporeal shock wave therapy) in patients with MPS (myofascial pain syndrome) in trapezius muscle are as effective as TPI (trigger point injections) and TENS (transcutaneous electrical nerve stimulation) for the purpose of pain relief and improving cervical range of motion."

Jeong SH, Oh SY, Kim HJ et al. 2009.  Vestibular dysfunction in migraine: effects of associated vertigo and motion sickness.  J Neurol. [Dec 30 Epub ahead of print]  “Innate hypersensitivity of the vestibular system may be an underlying mechanism of motion sickness and increased TC (time constant) in MD/MV (migrainous dizziness/vestibular migraine).  The increased tilt suppression may be an adaptive cerebellar mechanism to suppress the hyperactive vestibular system in migraineurs.”  [Vestibular dysfunction, migraines, FM and TrPs often occur in the same patient, and it can be difficult to figure out what symptoms are from which source.  Since TrPs are treatable, it may help to treat them and then see what remains. DJS]

Jerschow E, McGinn AP, de Vos G. et al. 2012. Dichlorophenol-containing pesticides and allergies: results from the US National Health and Nutrition Examination Survey 2005-2006. Ann Allergy Asthma Immunol. 109(6):420-425. "High urine levels of dichlorophenols are associated with the presence of sensitization to foods in a US population. Excessive use of dichlorophenols may contribute to the increasing incidence of food allergies in westernized societies. [We must be diligent about being more aware and concerned about our environment. As we pollute it, it pollutes us. DJS]

Jespersen A, Dreyer L, Kendall S et al. 2007.  Computerized cuff pressure algometry: a new method to assess deep-tissue hypersensitivity in fibromyalgia.  Pain. [Jan 24 Epub ahead of print]  This is yet another study confirming Dr. J. B. Eisinger’s development of FMS diagnostic testing using tensiometry, or blood pressure cuff tension.  I believe that this article would have benefitted by inclusion of Dr. Eisinger’s work. DJS]

Jessen NA, Munk AS, Lundgaard I, Nedergaard M. 2015. The Glymphatic System: A Beginner's Guide. Neurochem Res. 40(12):2583-2599. "The glymphatic system is a recently discovered macroscopic waste clearance system that utilizes a unique system of perivascular tunnels, formed by astroglial cells, to promote efficient elimination of soluble proteins and metabolites from the central nervous system. Besides waste elimination, the glymphatic system also facilitates brain-wide distribution of several compounds, including glucose, lipids, amino acids, growth factors, and neuromodulators. Intriguingly, the glymphatic system function mainly during sleep and is largely disengaged during wakefulness. The biological need for sleep across all species may therefore reflect that the brain must enter a state of activity that enables elimination of potentially neurotoxic waste products, including beta amyloid (implicated in Alzheimer's)."

Jesus CA, Feder D, Peres MF. 2013. The role of vitamin D in pathophysiology and treatment of fibromyalgia. Curr Pain Headache Rep. 17(8):355. "The association between fibromyalgia and vitamin D deficiency is very controversial in the literature with conflicting studies and methodological problems, which leads to more questions than answers. The purpose of this article is to raise questions about the association of hypovitaminosis D with fibromyalgia considering causal relationships, treatment, and pathophysiological explanations."

Jevning, R., I. Wells, A. F. Wilson and S. Guich.  1987.  Plasma thyroid hormones, thyroid stimulating hormone, and insulin during acute hypometabolic states in man.  Physiol Behav 40(5):603-6.

Jevning, R., A. F. Wilson and J. M. Davidson.  1978.  Adrenocortical activity during meditation. Horm Behav 10(1):54-60.  

Ji HM, Kim HJ, Han SJ. 2012. Extracorporeal shock wave therapy in myofascial pain syndrome of upper trapezius. Ann Rehabil Med. 36(5):675-680. "ESWT (extracorporeal shock wave therapy) in myofascial pain syndrome of upper trapezius is effective to relieve pain after four times therapies in two weeks. But further study will be required with more patients, a broader age range and more males."

Ji RR, Berta T, Nedergaard M. 2013. Glia and pain: Is chronic pain a gliopathy? Pain. Jun 20. [Epub ahead of print] "Activation of glial cells and neuro-glial interactions are emerging as key mechanisms underlying chronic pain. Accumulating evidence has implicated 3 types of glial cells in the development and maintenance of chronic pain: microglia and astrocytes of the central nervous system (CNS), and satellite glial cells of the dorsal root and trigeminal ganglia. Painful syndromes are associated with different glial activation states: (1) glial reaction (ie, upregulation of glial markers such as IBA1 and glial fibrillary acidic protein (GFAP) and/or morphological changes, including hypertrophy, proliferation, and modifications of glial networks); (2) phosphorylation of mitogen-activated protein kinase signaling pathways; (3) upregulation of adenosine triphosphate and chemokine receptors and hemichannels and downregulation of glutamate transporters; and (4) synthesis and release of glial mediators (eg, cytokines, chemokines, growth factors, and proteases) to the extracellular space. Although widely detected in chronic pain resulting from nerve trauma, inflammation, cancer, and chemotherapy in rodents, and more recently, human immunodeficiency virus-associated neuropathy in human beings, glial reaction (activation state 1) is not thought to mediate pain sensitivity directly. Instead, activation states 2 to 4 have been demonstrated to enhance pain sensitivity via a number of synergistic neuro-glial interactions. Glial mediators have been shown to powerfully modulate excitatory and inhibitory synaptic transmission at presynaptic, postsynaptic, and extrasynaptic sites. Glial activation also occurs in acute pain conditions, and acute opioid treatment activates peripheral glia to mask opioid analgesia. Thus, chronic pain could be a result of "gliopathy," that is, dysregulation of glial functions in the central and peripheral nervous system. In this review, we provide an update on recent advances and discuss remaining questions."

Jiang Q, Zhang L, Ding G et al. 2016. Impairment of the glymphatic system after diabetes. J Cereb Blood Flow Metab. [Jun 15 Epub ahead of print.] "The glymphatic system has recently been shown to clear brain extracellular solutes and abnormalities in glymphatic clearance system may contribute to both initiation and progression of neurological diseases… Type-2 diabetes mellitus suppresses clearance of interstitial fluid in the hippocampus and hypothalamus, suggesting that an impairment of the glymphatic system contributes to Type-2 diabetes mellitus-induced cognitive deficits." [Although this was done in rats, it indicates cranial swelling due to dysfunction of the glymphatic system may be critical in cognitive dysfunction found in other conditions such as fibromyalgia. DJS.]

Jiao J, Vincent A, Cha SS et al. 2014. Relation of age with symptom severity and quality of life in patients with fibromyalgia. Mayo Clin Proc. 89(2):199-206. "Our study shows that symptom severity and QOL differ across age groups in patients with fibromyalgia, with young and middle-aged patients having poorer QOL and worse fibromyalgia symptoms than do older patients. QOL in physical health was reduced more than in mental health, particularly in young patients, compared with the general population." [Possibly due to myofascial trigger points, the symptom generators, becoming latent. DJS]

Jimenez-Rodríguez I, Garcia-Leiva JM, Jimenez-Rodriguez BM et al. 2014. Suicidal ideation and the risk of suicide in patients with fibromyalgia: a comparison with non-pain controls and patients suffering from low-back pain. Neuropsychiatr Dis Treat. 10:625-630. "Fibromyalgia is associated with an increased rate of mortality from suicide. In fact, this disease is associated with several characteristics that are linked to an increased risk of suicidal behaviors, such as being female and experiencing chronic pain, psychological distress, and sleep disturbances.… The likelihood for suicidal ideation and the risk of suicide were higher among patients with fibromyalgia (odds ratios of 26.9 and 48.0, respectively) than in patients with low-back pain (odds ratios 4.6 and 4.7, respectively). Depression was the only factor associated with suicidal ideation or the risk of suicide." [How much of this is associated with feelings of helplessness, hopelessness, and lack of support from family, companions and medical team we can only guess. DJS]

Jimenez-Sanchez S, Jimenez-Garcia R, Hernandez-Barrera V et al. 2011. Invalidating musculoskeletal pain is associated with psychological distress and drug consumption: a Spanish population case-control study. J Musculoskel Pain. 19(2):76-86. "The IMP (invalidating musculoskeletal pain) subjects showed two times more probability of presenting psychological distress compared to those without pain. Women with IMP had more probability of suffering from psychological distress than men. Finally, psychological distress was related to a greater consumption of tranquilizers." Educating care providers and companions of peopel with TrPs is a key to their psychological health.

Jobanputra C, Richey RH, Nair J et al. 2017. Fibromyalgia in Behçet's disease: a narrative review. Br J Pain. 11(2):97-101. "Fibromyalgia is characterised by chronic widespread pain and tenderness. It has often been reported to occur concomitantly with chronic rheumatological conditions. Behçet's disease is a chronic relapsing, multisystem, autoinflammatory disease. There is only limited understanding of a potential relationship between fibromyalgia and Behçet's disease….This review provides some evidence that fibromyalgia is more prevalent in those with Behçet's disease. To ensure appropriate patient treatment choices, it is important that both conditions are diagnosed where they co-exist." Free Article [FM does not occur alone. Look for what is causing and maintaining the central sensitization. DJS]

Joergensen TS, Henriksen M, Danneskiold-Samsoe B et al. 2013. Experimental knee pain evokes spreading hyperalgesia and facilitated temporal summation of pain. Pain Med 14(6):874-883. " Why hypertonic saline was injected into the infrapatellar knee pad in healthy individuals, hyperalgesia and facilitated temporal summation (wind-up) resulted. When isotonic saline was injected into the same area of each patient on the other knee, no changes were noted. …Hyperalgesia can be created by pain, even in people with no history of pain."

Joerges J, Schulz T, Wegner J et al. 2012. Regulation of cell volume by glycosaminoglycans. J Cell Biochem. 13(1):340-348. "Hyaluronidase treatment of inhibition of hyaluronan transport led to cell shrinkage indicating that the hyaluronan (hyaluronic acid) coat maintained fibroblasts (the most common type of connective tissue cell) in a swollen state." [This research meshes well with the studies we did on geloid masses inpatients with FM and CMP, and indicates that patients with FM and CMP may need to be very careful using any product with hyaluronic acid. That is a component in many cosmetics, body lotions, and anti-aging formulas. DJS]

Johanson E, Brumagne S, Janssens L et al. 2011. The effect of acute back muscle fatigue on postural control strategy in people with and without recurrent low back pain. Eur Spine J. [May 1 Epub ahead of print]. "...these findings suggest that impaired back muscle function, as a result of acute muscle fatigue or pain, may lead to an inability to adapt postural control strategies to the prevailing conditions." When we are hurt or fatigued, we are less able to control our gross motor function and posture, and more likely to be injured.

Johnson EO, Babis GC, Soultanis KC et al. 2008. Functional neuroanatomy of proprioception. J Surg Orthop Adv. 17(3):159-164. "Proprioception is the sense of body position that is perceived both at the conscious and unconscious levels. Typically, it refers to two kinds of sensations: that of static limb position and of kinesthesia. Static position reflects the recognition of the orientation of the different body parts, whereas kinesthesia is the recognition of rates of movement." [This is a very relevant and important review. When care providers who know myofascial medicine think of TrPs, they often think only of pain. Associated proprioceptive and autonomic dysfunctions are important as well, as are muscle dysfunctions such as weakness caused by TrPs, but this often goes unrecognized. DJS]

Johnson JD, O’Connor KA, Deak T et al. 2002.  Prior stressor exposure primes the HPA axis.  Psychoneuroendocrinology 27(3):353-365. 

Johnson JD, O’Connor KA, Deak T et al.  Psychoneuroendocrinology. 27(3):353-365.  The stress response in rats is changed after an initial HPA activation.  Neural plasticity is affected by stress, at least in rats.

Johnson M, Collett B, Castro-Lopes JM. 2013. The challenges of pain management in primary care: a pan-European survey. J Pain Res. 6:393-401. "A survey was conducted to assess the challenges of chronic nonmalignant pain (CNMP) management in primary care in Europe, focusing particularly on pain assessment, opioid therapy, and educational needs….These findings reveal that PCPs (Primary Care Physicians) in Europe find CNMP a challenge to treat. Areas to address with training include underuse of pain assessment tools and lack of confidence in use of opioid therapy. Guidelines on CNMP management in primary care would be welcomed."

Jones AY, Dean E, Scudds RJ. 2005.  Effectiveness of a community-based Tai Chi program and implications for public health initiatives.  Arch Phys Med Rehabil. 86(4):619-625.  “A community-based Tai Chi program produces beneficial effects comparable to those reported from experimental laboratory trials of Tai Chi; therefore, it should be considered as a public health strategy.”  The regular practice of t’ai chi improves handgrip strength, resting heart rate, and flexibility.

Jones CJ, Rutledge DN, Aquino J. 2010. Predictors of physical performance and functional ability in people 50+ with and without fibromyalgia. J Aging Phys Act. 18(3):353-368. "The purposes of this study were to determine whether people with and without fibromyalgia (FM) age 50 yr and above showed differences in physical performance and perceived functional ability and to determine whether age, gender, depression, and physical activity level altered the impact of FM status on these factors.... Results indicated significant differences between adults with and without FM on all physical-performance measures and perceived function. Linear-regression models showed that the contribution of significant predictors was in expected directions. All regression models were significant, accounting for 16-65% of variance in the dependent variables."

Jones GT, Atzeni F, Beasley M et al. 2014. The prevalence of fibromyalgia in the general population - a comparison of the American College of Rheumatology 1990, 2010 and modified 2010 classification criteria. Arthritis Rheumatol. Oct 16. "Fibromyalgia prevalence varies with the different classification criteria - specifically, prevalence is higher, and a greater proportion of men are identified, with the modified 2010 criteria, compared to those requiring clinician input. This has important implications for the use of the new criteria both in research and in clinical practice."

Jones GT, Nicholl BI, McBeth J et al. 2011. Road traffic accidents, but not other physically traumatic events, predict the onset of chronic widespread pain: Results from the EpiFunD study. Arthritis Care Res (Hoboken). [Mar 21 Epub ahead of print]. "This study provides support to the 'at risk' phenotype hypothesis, where individuals characterized by poorer health and psychological variables may be predisposed to develop CWP following a traumatic trigger. However, while this has been seen with road traffic accidents it is not the case with other events. Future research should examine what is peculiar about an accident - or about one's reaction to it - that confers this increase in the risk of CWP onset."

Jones KD, Aebischer JH, St John AW et al. 2017. A simple screening test to recognize fibromyalgia in primary care patients with chronic pain. J Eval Clin Pract. [Oct 23 Epub ahead of print] "On further analyses, a useful screening test was provided by: (1) pain on pinching the Achilles tendon at 4 kg/pressure over 4 seconds, and (2) and positive endorsement of the question 'I have a persistent deep aching over most of my body'. 2 tests, taking less than 1 minute, can indicate a probable diagnosis of FM in a chronic pain patient. In the case of a positive screen, a follow-up examination is required for confirmation or refutation."

Jones KD, Gelbart T, Whisenant TC et al. 2016. Genome-wide expression profiling in the peripheral blood of patients with fibromyalgia. Clin Exp Rheumatol. 34(2 Suppl 96):89-98. "Fibromyalgia patients exhibited a differential expression of 421 genes…. several relevant to pathways for pain processing, such as glutamine/glutamate signaling and axonal development. There was also an upregulation of several inflammatory pathways and downregulation of pathways related to hypersensitivity and allergy.… Lastly, we identified a subset of 10 probesets that provided a diagnostic sensitivity for FM of 95% and a specificity of 96%. We also show that the signatures for FM were very specific to FM rather than common FM comorbidities….These findings provide new insights relevant to the pathogenesis of FM, and provide several testable hypotheses that warrant further exploration and also establish the foundation for a first blood-based molecular signature in FM that needs to be validated in larger cohorts of patients." Free PMC Article

Jones KD, King LA, Mist SD et al. 2011. Postural control deficits in people with fibromyalgia: a pilot study. Arthritis Res Ther. 13(4):R127. "Postural instability and falls are increasingly recognized problems in fibromyalgia (FM). The purpose of this study was to determine if FM patients, compared to age-matched controls, had differences in dynamic posturography, including sensory, motor, and limits of stability. We further sought to determine if postural instability was associated with strength, proprioception and lower extremity myofascial trigger points (MTPs), FM symptoms and physical function, dyscognition, balance confidence and medication usage. Lastly, we evaluated self-report of falls over the past six months....This study reports that middle-aged FM patients have: consistent objective sensory deficits on dynamic posturography, despite having a normal clinical neurological exam. Further study is needed to determine prospective fall rates and the significance of lower extremity MTPs. The development of interventions to improve balance and reduce falls in FM patients may need to combine balance training with exercise and cognitive training." [It is good that TrPs are considered in FM studies, but it would be helpful to include upper body TrPs in future studies, as dizziness and imbalance are often associated with sternocleidomastoid and other upper body TrPs. The inclusion of a diagnostic check for vestibular dysfunction, a common co-existing condition of FM, would also be helpful. DJS]

Jones KD, Mist SD, Bennett RM et al. 2010. Computerized dynamic posturography reveals balance deficits in fibromyalgia patients comparable to healthy persons in their eighth decade. International Myopain Society Eighth Clinical Meeting Oct 3-7, 2010. Toledo, Spain. Abstract No. 48. "FM patients, compared to controls, are more likely to experience falls and have poor balance related to impaired use of visual, vestibular and somatosensory inputs. Deficits are related to FM severity, an elevated BMI and impaired cognition." [FM patients often have co-existing TrPs with concomitant proprioceptive deficits, FM chemical traumatic brain impairments such as those due to quinolinic acid production, co-existing traumatic brain injury and/or vestibular dysfunction as well as visual impairments. All of these and other forms of balance impairments (many TrPs are significantly linked to balance and gait irregularities) must be identified and treated vigorously. This could save countless hip replacement and other surgeries, other injuries and hospitalizations, and even deaths. DJS]

Jones KD, Sherman CA, Mist SD et al. 2012. A randomized controlled trial of 8-form Tai chi improves symptoms and functional mobility in fibromyalgia patients. Clin Rheumatol. [May 13 Epub ahead of print]. This study used an FM-modified 8-form Yang style tai chi compared to those that had education only. Small groups of patients met twice a week for 90 minutes, over 12 weeks, with a goal of self-reported symptom reduction. The patients in the tai chi groups had better results in pain, sleep, function, and other parameters than the group that was provided with education only. "Twelve weeks of Tai chi, practice twice weekly, provided worthwhile improvement in common FM symptoms including pain and physical function including mobility. Tai chi appears to be a safe and an acceptable exercise modality that may be useful as adjunctive therapy in the management of FM patients."

Joranson DE, Gilson AM. 2001.  Pharmacists’ knowledge of and attitudes toward opioid pain medications in relation to federal and state policies.  J Am Pharm Assoc 41(2):213-220.  “Pharmacists play a pivotal role in ensuring patient access to medications.  Our findings suggest that the incorrect knowledge and inappropriate attitudes of some pharmacists could contribute to a failure to dispense valid prescriptions for opioid analgesics to patients in pain.”  [This is a very sad yet accurate commentary on one more hurdle that some chronic pain patients must overcome to gain access to adequate pain control.]

Joranson DE, Ryan KM, Gilson AM et al. 2000.  Trends in medical use and abuse of opioid analgesics.  JAMA 283(13):1710-1714.  “The trend of increasing medical use of opioid analgesics to treat pain does not appear to contribute to increases in the health consequences of opioid analgesic abuse.” "Between 1990-1996 the use of all agents, with the exception of meperidine, increased from between 19% and 59%.  Drug abuse due to opioids and narcotics increased by only 6.6%.  As a proportion of all drug abuse, narcotic abuse decreased by 2% in the same period.  Specifically, abuse of meperidine decreased by 39%, oxycodeine by 29%, fentanyl by 59%, and hydromorphine by 15%.  There was a 3% increase in drug abuse related to morphine."

Joranson, D. E. and A. M. Gilson.  1998.  Regulatory barriers to pain management.  Semin Oncol Nurs 14(2):158-63.

Joranson, D. E.  1990.  Federal and state regulation of opioids.  J Pain Symptom Manage5(1 Suppl):S12-S23.

Jorge LL, Amaro E Jr. 2012. Brain Imaging in Fibromyalgia. Curr Pain Headache Rep. [Jun 21 Epub ahead of print]. "Fibromyalgia is a primary brain disorder or a result of peripheral dysfunctions inducing brain alterations, with underlying mechanisms that partially overlap with other painful conditions. Although there are methodologic variations, neuroimaging studies propose neural correlations to clinical findings of abnormal pain modulation in fibromyalgia. Growing evidences of specific differences of brain activations in resting states and pain-evoked conditions confirm clinical hyperalgesia and impaired inhibitory descending systems, and also demonstrate cognitive-affective influences on painful experiences, leading to augmented pain-processing. Functional data of neural activation abnormalities parallel structural findings of gray matter atrophy, alterations of intrinsic connectivity networks, and variations in metabolites levels along multiple pathways. Data from positron-emission tomography, single-photon-emission-computed tomography, blood-oxygen-level-dependent, voxel-based morphometry, diffusion tensor imaging, default mode network analysis, and spectroscopy enable the understanding of fibromyalgia pathophysiology, and favor the future establishment of more tailored treatments."

Joyce, E., S. Blumentahl and S. Wessely. 1996.  Memory, attention and executive function in chronic fatigue syndrome.  J Neurol Neurosurg Psychiatry 60(5):459-503.

Juhl GI, Jensen TS, Norholt SE et al. 2007.  Central sensitization phenomena after third molar surgery: a quantitative sensory testing study.  Eur J Pain. [Jun 4 Epub ahead of print]  “Even a minor orofacial surgical procedure may be sufficient to evoke signs of both central and peripheral sensitization, which may play a role in the transition from acute to chronic pain in susceptible individuals.” 

Juuso P, Skar L, Olsson M et al. 2014. Meanings of Being Received and Met by Others as Experienced by Women with Fibromyalgia. Qual Health Res. [Aug 21 Epub ahead of print.] "Fibromyalgia (FM) is a common chronic pain syndrome that mostly affects middle-aged women. Our aim with this study was to elucidate meanings of being received and met by others as experienced by women with FM. Interviews with a narrative approach were conducted with 9 women. We analyzed the transcribed interviews with a phenomenological hermeneutical interpretation. The findings revealed two themes: being seen as a malingerer and being acknowledged. Meanings of being received and met by others, as experienced by women with FM, can be understood as a movement between the two perspectives. When they were acknowledged, their feelings of security and trust increased, but the women could not rely on this because others received and met them in such an unpredictable manner."

Juuso P, Skar L, Olsson M et al. 2012. Meanings of Feeling Well for Women with Fibromyalgia. Health Care Women Int. [Nov 8 Epub ahead of print]. "Our interpretation of the findings shows that for women with FM meanings of feeling well can be understood as having strength to be involved. The women's experiences of feeling well meant being in control, having power, finding one's own pace, and experiencing feelings of belonging."

Juuso P, Skar L, Olsson M et al. 2011. Living with a double burden: meanings of pain for women with fibromyalgia. Int J Qual Stud Halth Well-being. 6(3). "The findings show that meanings of pain for women with FM can be understood as living with a double burden; living with an aggressive, unpredictable pain and being doubted by others in relation to the invisible pain. The ever-present pain was described as unbearable, overwhelming, and dominated the women's whole existence. Nevertheless, all the women tried to normalize life by doing daily chores in an attempt to alleviate the pain. In order to support the women's needs and help them to feel well despite their pain, it is important that nurses and health care personnel acknowledge and understand women with FM and their pain experiences."

Juuso P, Soderberg S, Olsson M et al. 2013. The significance of FM associations for women with FM. Disabil Rehabil. [Dec 18 Epub ahead of print.] "Living with fibromyalgia (FM) means living with a long-term pain syndrome that is invisible to others. Support and understanding from others seem to be important to managing the affected daily life….The findings show that women experienced associations for people with FM as important as they gave access to contacts with others with similar experiences. Their need of togetherness was fulfilled at the association and they described being strengthened by the support received. Because of the lack of information and knowledge about FM, the association was described as an important venue for getting and mediating information about the illness. ….At the association the women seem to be empowered, which increases their ability to manage their daily lives despite the limitations imposed by FM. Healthcare personnel could not satisfy the women's needs and to manage to support women with FM. There is a need for communication based on a shared understanding between the women and healthcare personnel. Implications for Rehabilitation This study highlighted the need for communication based on a shared understanding between people with chronic illness and healthcare personnel to support and strengthen women with FM in their daily lives. The FM associations meet the needs for togetherness, confirmation, and information that the women with FM in this study described and healthcare personnel could not satisfy. Healthcare personnel can learn from FM associations how to empower women with FM in their everyday lives."

Kahan M, Srivastava A, Wilson L et al. 2006.  Opioids for managing chronic non-malignant pain: safe and effective prescribing.  Can Fam Physician. 52(9):1091-1096.  When pain control with other medications have failed, titration to find the lowest dose opioids that might be effective is the next logical step.  “Most patients with chronic non-malignant pain can be managed with <300 mg/d of morphine (or equivalent).  Opioids are safe and effective for managing chronic pain.”  [Non-medicinal pain relief methods should be part of any pain control program. DJS]

Kalangara JP, Galor A, Levitt RC et al. 2015. Burning eye syndrome: Do neuropathic pain mechanisms underlie chronic dry eye? Pain Med. [Dec 24 Epub ahead of print.] "Dry eye is becoming a major health concern due to its increasing incidence, significant morbidity, and economic burden. Recent evidence suggests that a subset of dry eye may be better represented as a chronic neuropathic pain disorder due to its features of dysesthesia, spontaneous pain, allodynia, and hyperalgesia. Future therapies targeted at the underlying neuroplasticity may yield improved efficacy for patients with this subset of dry eye, which we term 'burning eye syndrome.'"

Kalichman L, Bulanov N, Friedman A. 2017. Effect of exams period on prevalence of myofascial trigger points and head posture in undergraduate students: Repeated measurements study. J Bodyw Mov Ther. 21(1):11-18. "Myofascial Trigger points (MTrPs) may be caused or aggravated by many factors, such as mental stress associated with exams and impaired (head-forward) posture." Physical therapy students were tested for TrP sensitivity and head forward posture during exam times and between exams. "The subjects showed higher prevalence of active MTrPs in the right Trapezius and Levator Scapula muscles, and higher prevalence of latent MTrPs in the left Sternocleidomastoideus and Levator Scapula muscles during exams, as well as a higher rate of tenderness in suboccipital musculature.".

Kalichman L, Levin I, Bachar I et al. 2018. Short-term effects of kinesio taping on trigger points in upper trapezius and gastrocnemius muscles. J Bodyw Mov Ther. 22(3):700-706. "We demonstrated that a kinesio taping application positioned directly above the MTrPs may prevent an increase in sensitivity (decrease in PPT) immediately after application and prevent further sensitization up to 24 h later. The fact that two different muscles were similarly affected by the kinesio taping application, confirmed that the results were not in error. Further studies are needed to directly test the effect of a kinesio taping application on post-treatment soreness."

Kalichman L, Vulfsons S. 2010. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med. 23(5):640-646. "Myofascial pain is a common syndrome seen by family practitioners worldwide. It can affect up to 10% of the adult population and can account for acute and chronic pain complaints. In this clinical narrative review we have attempted to introduce dry needling, a relatively new method for the management of musculoskeletal pain, to the general medical community. Different methods of dry needling, its effectiveness, and physiologic and adverse effects are discussed. Dry needling is a treatment modality that is minimally invasive, cheap, easy to learn with appropriate training, and carries a low risk. Its effectiveness has been confirmed in numerous studies and 2 comprehensive systematic reviews. The deep method of dry needling has been shown to be more effective than the superficial one for the treatment of pain associated with myofascial trigger points. However, over areas with potential risk of significant adverse events, such as lungs and large blood vessels, we suggest using the superficial technique, which has also been shown to be effective, albeit to a lesser extent. Additional studies are needed to evaluate the effectiveness of dry needling. There also is a great need for further investigation into the development of pain at myofascial trigger points."

Kallenberg LA, Hermens HJ. 2004.  Motor unit action potential rate and motor unit action potential shape properties in subjects with work-related chronic pain.  Eur J Appl Physiol. [Epub ahead of print.]  “...more high-threshold Mus contribute to low-level computer work-related tasks in chronic pain cases. Additionally, the results suggest that the input of the central nervous system to the muscle is higher in the cases with chronic pain.”

Kalmer, J. M. and E. Cafarelli1999. Effects of caffeine on neuromuscular function. A Appl Physiol 87(2):801-808.

Kamali F, Sinaei E, Morovati M. 2018. Comparison of upper trapezius and infraspinatus myofascial trigger point therapy by dry needling in overhead athletes with unilateral shoulder impingement syndrome. J Sport Rehabil. 24:1-24. "Chronic musculoskeletal disorders in shoulder joint are often associated with myofascial trigger points (MTrP), particularly in the upper trapezius (UT) muscle. Dry needling (DN) is a treatment of choice for myofascial pain syndrome. However, local lesions and severe post-needle soreness sometimes hamper the direct application of DN in the UT. Therefore, finding an alternative point of treatment seems useful in this regard....Application of DN for active MTrPs in the ISP can be as effective as direct DN of active MTrPs in the UT in improving pain and disability in athletes with shoulder pain, and may be preferred due to greater patient comfort in comparison with direct UT needling."

Kamanli A, Kaya A, Ardicoglu O et al. 2004.  Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome.  Rheumatol Int. [Epub ahead of print.]  Lidocaine injection appears to offer the best results of the three according to this study, as it causes less problems than the dry needling and is less expensive than BTX-A.  BTX-A may be the treatment of choice in patients with resistant TrPs.  [Perpetuating factors must always be identified and brought under control.  DJS.]

Kandt RS, Daniel FL. 1986.  Glossopharyngeal neuralgia in a child.  A diagnostic and therapeutic dilemma.  Arch Neurol 43(3):301-302.  Symptoms were caused by TrPs in the right tonsil area.

Kang W, Hong HJ, Guan J et al. 2012. Reservatrol improves insulin signaling in a tissue-specific manner under insulin-resistant conditions only: in vitro and in vivo experiments in rodents. Metabolism 61(3):424-433. This study showed that in mice, reservatrol enhanced insulin action and normalized metabolism only under insulin-resistant conditions. It may act differently or not at all, depending on what type tissue is being targeted and whether or not the metabolic state is insulin-resistant or not.

Kang Y, Yi Y, Kim J. 2007.  Pain drawings of the phantom pain of the patients with amputation.  J Musculoskel Pain 15 (Supp 13):27 item 43.  [Myopain 2007 Poster]  “The patterns of phantom pain were very similar to the referred pain patterns of the MPS.  A new assumption would be possible: that ‘phantom pain in MPS’s clothing’ like ‘sheep in wolf’s clothing’.” [This finding agrees with other research and observation that indicates phantom limb (and breast, uterine and ovarian) pain may be due to MTPs or other tissue TrPs. DJS]

Kanlayananaphotporn R. 2014. Changes in sitting posture affect shoulder range of motion. J Bodyw Move Ther. 18(2):239-243. A slight, comfortable slouch can significantly affect shoulder range of motion. Even slight changes in the curve of the thoracic spine can affect shoulder range of motion, and must be taken into account during assessment.

Kannan P. 2012. Management of Myofascial Pain of Upper Trapezius: A Three Group Comparison Study. Glob J Health Sci. 4(5):46-52. "We conclude that laser can be used as an effective treatment regimen in the management of myofascial trigger points thereby reducing disability caused due to musculoskeletal pathology."

Kanti V, Ananthan S, Subramanian G et al. 2017. Efficacy of the twin block, a peripheral nerve block for the management of chronic masticatory myofascial pain: A case series. Quintessence Int. 6:725-729. "Masticatory myofascial pain is the one of the most common etiologies for nonodontogenic pain, often characterized by the presence of trigger points. Conventional management includes approaches such as jaw exercises, physical therapy, intraoral appliances, medications, and trigger point injections. Peripheral/regional nerve blocks have shown to be effective in managing myogenous pain conditions. The twin block is a nerve block that blocks both the masseteric and the anterior deep temporal nerves. The objective of this case series is to illustrate expeditious and sustained efficacy of the twin block in the management of chronic masticatory myofascial pain."

Kao MJ, Han TI, Chou LW et al. 2010. Development of myofascial trigger points in children. International Myopain Society Eighth Clinical Meeting Oct 3-7, 2010. Toledo, Spain. Abstract No. 8. "It was concluded that children began to develop an MTrP and an A-TrP at the brachioradialis muscle since at the age of 6 years, with the A-TrP becomes more irritable than in the MTrP since at the age of 7 years. These findings are not related to the activity levels." [Young people have TrPs, both attachment TrPs (ATrPs in tendons and ligaments) and MTrPs (myofascial TrPs.) They are a common source of growing pain, and they are treatable. They must be treated promptly (and gently), to prevent scoliosis and other bone deformities from developing, to prevent gait irregularities from causing further problems, and to prevent chronicity and central sensitization from developing. DJS]

Kapreli E, Vourazanis E, Strimpakos N. 2007.  Neck pain causes respiratory dysfunction.  Med Hypotheses [Oct 22 Epub ahead of print].  “The patient with neck pain presents a number of factors that could constitute a predisposition of leading to a respiratory dysfunction: (a) the decreased strength of deep neck flexors and extensors, (b) the hyperactivity and increased fatigability of superficial neck flexors, (c) the limitation of range of motion, (d) the decrease in proprioception and disturbances in neuromuscular control, (e) the existence of pain and (f) the psychosocial influence of dysfunction.  The possible connection of neck pain and respiratory function could have a great impact on various clinical aspects, notably patient assessment, rehabilitation and pharmacological prescription.”

Kaput J, Perlina A, Hatipoglu B et al. 2007.  Nutrigenomics: concepts and applications to pharmacogenomics and clinical medicine.  Pharmacogenomics. 8(4):369-390. “The maintenance of health and the prevention and treatment of chronic diseases are influenced by naturally occurring chemicals in foods.  In addition to supplying the substrates for producing energy, a large number of dietary chemicals are bioactive -- that is, they alter the regulation of biological processes and, either directly or indirectly, the expression of genetic information.  Nutrients and bioactives may produce different physiological phenotypes among individuals because of genetic variability and not only alter health, but also disease initiation, progression and severity.  The study and application of gene-nutrient interactions is called nutritional genomics or nutrigenomics.  Nutrigenomic concepts, research strategies and clinical implementation are similar to and overlap those of pharmacogenomics, and both are fundamental to the treatment of disease and maintenance of optimal health.”

Kaput J, Rodriguez RL. 2004.  Nutritional genomics: the next frontier in the post genomic era.  Physiol Genomics. 16(2):166-177. “…dietary intervention based on knowledge of nutritional requirement, nutritional status, and genotype (i.e., ‘individualized nutrition’) can be used to prevent, mitigate, or cure chronic disease.”

Karadas O, Gul HL, Inan LE. 2013. Lidocaine injection of pericranial myofascial trigger points in the treatment of frequent episodic tension-type headache. J Headache Pain. 14:44. "Local lidocaine injections into the myofascial TPs located in the pericranial muscles could be considered as an effective alternative treatment for ETTH (episodic tension-type headache)."

Karalis, K. P., E. Kontopoulos, L. J. Muglia and J. A. Majzoub.  1999.  Corticotropin-releasing hormone deficiency unmask the proinflammatory effect of epinephrine.  Proc Natl Acad Sci U S A 96(12):7093-7.   

Karavis MY, Argyra E, Segredos V et al. 2015. Acupuncture-induced haemothorax: a rare iatrogenic complication of acupuncture. Acupunct Med. [Mar 19 Epub ahead of print.] "This paper reports a rare iatrogenic complication of acupuncture-induced haemothorax and comments on the importance and need for special education of physicians and physiotherapists in order to apply safe and effective acupuncture treatment. A 37-year-old healthy woman had a session of acupuncture treatments for neck and right upper thoracic non-specific musculoskeletal pain, after which she gradually developed dyspnoea and chest discomfort. After some delay while trying other treatment, she was eventually transferred to the emergency department where a chest X-ray revealed a right pneumothorax and fluid collection….To maximize the safety of acupuncture, specific training should be given for the safe use of acupuncture points of the anterior and posterior thoracic wall using dry needling, trigger point acupuncture or other advanced acupuncture techniques."

Karim MR, Fann AV, Gray RP et al. 2005.  Enthesitis of biceps brachii short head and coracobrachialis at the coracoid process: a generator of shoulder and neck pain.  Am J Phys Med Rehabil. 84(5):376-380.  [This study used Marcaine and DepoMedrol for anterior shoulder pain and MPS, with a diagnosis of enthesitis.  It would be interesting to know what would have happened if the patients had been examined for attachment trigger points and injected with procaine or lidocaine.  A less toxic local anesthetic may often be effective for enthesiopathy caused by attachment trigger points.  DJS]

Karlsson B1, Burell G1, Anderberg UM et al. 2017. Cognitive behaviour therapy in women with fibromyalgia: A randomized clinical trial. Scand J Pain. 9(1):11-21. "FMS is a disorder with great therapeutic challenges. Total abolishment of pain symptoms is extremely difficult or impossible to achieve. Thus, the development of individual strategies for coping with pain is essential to reduce its impact on daily life. Since stress may worsen the pain experience, coping with stress might be a promising route to accomplishing that goal. In evaluations of interventions for pain it is important to monitor the effect on behaviour responses to pain and not only ratings of pain itself."

Karmakar MK, Ho AM. 2004.  Postthoracotomy pain syndrome.  Thorac Surg. Clin. 14(3):345-352.  About 30% of posthoracotomy patients experience chronic pain as a result.  The authors advocate aggressive pain control before incision, but neglect to mention the possibility of TrPs.

Karsdorp PA, Vlaeyen JW. 2009.  Active avoidance but not activity pacing is associated with disability in fibromyalgia.  Pain [Aug 26 Epub ahead of print].

Kasapoglu Aksoy M, Altan L, Okmen Metin. 2016. The relationship between balance and vitamin 25(OH)D in fibromyalgia patients. Mod Rheumatol. 16:1-18. [Epub ahead of print] "It was observed that low vitamin D levels affected balance in both FMS group and healthy control group. It should be kept in mind that vitamin D level is likely to negatively affect balance and VAS values in FMS."

Kashikar-Zuck S, Cunningham N, Sil S et al. 2014. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. [Feb 24 Epub ahead of print.] "Adolescent patients with JFM have a high likelihood of continued fibromyalgia symptoms into young adulthood. Those who met criteria for fibromyalgia in adulthood exhibited the highest levels of physical and emotional impairment. Emerging differences in educational attainment and marital status were also found in the JFM group. JFM is likely to be a long-term condition for many patients, and this study for the first time describes the wide-ranging impact of JFM on a variety of physical and psychosocial outcomes that seem to diverge from their same-age peers."

Kashikar-Zuck S, Johnston M, Ting TV et al. 2010. Relationship between school absenteeism and depressive symptoms among adolescents with juvenile fibromyalgia. J Pediatr Psychol. [Apr 1 Epub ahead of print]. “Over 12% of adolescents with JPFS (juvenile primary fibromyalgia syndrome) were home schooled. Those enrolled in regular school missed 2.9 days per month on average, with one-third of participants missing more than 3 days per month. Pain and maternal pain history were not related to school absenteeism. However, depressive symptoms were significantly associated with school absences. Conclusion: Many adolescents with JPFS experience difficulties with regular school attendance.”  [This conclusion is not unexpected yet the study is needed.  It is hoped that teachers will learn basic signs of both fibromyalgia and myofascial trigger points.  These common conditions can directly affect the ability of the student to learn, and there are many things that can be done to improve the learning experience for these students.  The sooner early warning signs of these conditions such as unrestorative sleep and growing pains are caught, the better the prognosis for the patient and the more efficient the education efforts can be. DJS]

Kashikar-Zuck S, King C2, Ting TV et al. 2016. Juvenile fibromyalgia: Different from the adult chronic pain syndrome? Curr Rheumatol Rep. 18(4):19. "While a majority of research has focused on adult fibromyalgia (FM), recent evidence has provided insights into the presence and impact of FM in children and adolescents. Commonly referred as juvenile fibromyalgia (JFM), youths, particularly adolescent girls, present with persistent widespread pain and cardinal symptoms observed in adult FM. A majority of youth with JFM continue to experience symptoms into adulthood, which highlights the importance of early recognition and intervention. Some differences are observed between adult and juvenile-onset FM syndrome with regard to comorbidities (e.g., joint hypermobility is common in JFM). Psychological comorbidities are common but less severe in JFM. Compared to adult FM, approved pharmacological treatments for JFM are lacking, but non-pharmacologic approaches (e.g., cognitive-behavioral therapy and exercise) show promise. A number of conceptual issues still remain including (1) directly comparing similarities and differences in symptoms and (2) identifying shared and unique mechanisms underlying FM in adults and youths."

Kashikar-Zuck S, Lynch AM, Graham TB et al. 2007.  Social functioning and peer relationships of adolescents with juvenile fibromyalgia syndrome.  Arthritis Rheum. 57(3):474-480.  “Adolescents with JPFS were perceived (by peer and self reports) as being more isolated and withdrawn and less popular.  Adolescents with JPFS were less well liked, were selected less often as a best friend, and had fewer reciprocated friendships.”  “Given the central role that peer relationships play in psychological development of children, and because peer rejection and isolation have been associated with subsequent adjustment problems, these findings are concerning.”  [This is a significant study and indicates a great need for more attention to the support systems of adolescents with FM. DJS]

Kashikar-Zuck S, Zafar M, Barnett KA et al. 2013. Quality of life and emotional functioning in youth with chronic migraine and juvenile fibromyalgia. Clin J Pain. [Feb 26 Epub ahead of print]. "Chronic pain in children is associated with significant negative impact on social, emotional and school functioning." "Youth with JFM (juvenile fibromyalgia) had significantly higher anxiety and depressive symptoms, and lower quality of life in all domains. Among children with CM (chronic migraine), overall functioning was higher but school functioning was a specific area of concern….Results indicate important differences in subgroups of pediatric pain patients and point to the need for more intensive multidisciplinary intervention for JFM patients."

Kasikcioglu E, Dinler M, Berker E. 2006.  Reduced tolerance of exercise in fibromyalgia may be a consequence of impaired microcirculation initiated by deficient action of nitric oxide.  Med. Hypotheses [Jan 9 Epub ahead of print].

Kaspiris A, Chronopoulos E, Vasiliadis E. 2016. Perinatal risk factors and genu valgum conducive to the onset of growing pains in early childhood. Children (Basel). 3(4):34. "The most prevalent musculoskeletal disorder of childhood with unclear aetiology is growing pains (GPs)…. The aim of our study was to analyze the relationship between GPs, knock knees and perinatal factors…. Genu valgum severity was a significant factor for GP manifestation and for their increased frequency and intensity. Subsequently, perinatal factors regarding gestational age, Apgar score, head circumference (lower than 33 cm) and birth length or weight (smaller than 50 cm and 3000 g, respectively) made a remarkable contribution to the development of GPs. Conversely, antenatal corticosteroid treatment, increased maternal age and maternal smoking during pregnancy were not predictive of the disorder. Our data are potentially supportive for the "bone strength" theory and for the contribution of anatomical disturbances in GP appearance." [The authors seemed unaware of trigger points, but they did catch the body asymmetry factors for growing pains, although Travell and Simons indicated that genu valgum is a perpetuating factor for trigger points. DJS]

Kassirer,  J. P. 1997. Federal foolishness and marijuana.  N Engl J Med 366(5):336-7.

Kasteleijn-Nolst Trenite, D. G., A. M. da Silva, S. Ricci, C. D. Binnie, G. Rubboli, C. A. Tassinari and J. P. Segers.  1999.  Video-game epilepsy: a European study.  Epilepsia 40 (Suppl 4):70-4.

Kasunich NJ. 2003.  Changes in low back pain in a long distance runner after stretching the iliotibial band.  J Chiropr Med. 2(1):37-40.  “This case report describes a long distance runner with low-back pain and sacroiliac pain and proposes iliotibial band tightness as a possible causative factor.  Clinical Features: A 38-year-old female amateur runner experienced an exacerbation of right-sided lower back and sacroiliac pain, which she had experienced for several months.”  “Trigger points were found in the gluteus maximus, gluteus medius, and tensor fascia lata muscles.”  “A patient had low back and sacroiliac pain that seemed to originate from a dysfunctional iliotibial band.  This case illustrates that it is important to consider iliotibial band tightness as a possible cause of low back and sacroiliac pain and that proper management may need to include stretching of the iliotibial band along with trigger point therapy and chiropractic manipulation.”  [TrPs in the iliotibial band are a frequently overlooked source of referred pain. DJS]

Katayama A, Kanada Y, Tsukada M et al. 2018. Yokukansan (Kampo medicinal formula) prevents the development of morphine tolerance by inhibiting the secretion of orexin A. Integr Med Res. 7(2):141-148."Yokukansan (YKS), a traditional herbal (Kampo) medicine consisting of seven herbs, is effective in the treatment of pain disorders, such as headache, postherpetic neuralgia, fibromyalgia, and trigeminal neuralgia, and we have previously shown it to be effective against morphine analgesic tolerance in rats. It has been reported that orexin receptor antagonists prevent the development of morphine tolerance and that YKS inhibits the secretion of orexin A in the hypothalamus. This study (Japan) examined whether the inhibition of the secretion of orexin A by YKS is one mechanism underlying its effect against morphine analgesic tolerance.... These results suggest that the preadministration of YKS (in rats) attenuated the development of antinociceptive morphine tolerance and that the inhibition of orexin A secretion may be one mechanism underlying this phenomenon."

Kathagen N, Prehm P. 2013. Regulation of intracellular pH by glycosaminoglycans. J Cell Physiol. 228(10):2071-2075. Addition of hyaluronan (hyaluronic acid), hyaluronan oligosaccharides, chondroitin sulfate, or heparin to culture medium of fibroblasts caused intracellular acidification from pH 7.2 to 6.7 in a concentration dependent manner. Acidification is associated with disease states. Hyaluronidase treatment or hyaluronidase export inhibition (with xanthhohumol) resulted in intracellular alkalization. This indicates that glycosaminoglycans participate in some way in intracellular pH regulation. [This research meshes well with the studies we did on geloid masses inpatients with FM and CMP, and indicates that patients with FM and CMP may need to be very careful using any product with hyaluronic acid. HA is a component in many cosmetics, body lotions, and anti-aging formulas. DJS]

Katic B, Heywood J, Turek F et al. 2015. New approach for analyzing self-reporting of insomnia symptoms reveals a high rate of comorbid insomnia across a wide spectrum of chronic diseases. Sleep Med. 16(11):1332-1341. "Insomnia is increasingly recognized to be comorbid with one or more medical conditions. …The high rate of severity and frequency of insomnia across a multitude of mental and physical conditions reveals an opportunity for better disease management through enhanced insomnia awareness." Free Article

Kato T, Montplaisir JY, Guitard F et al. 2003.  Evidence that experimentally induced sleep bruxism is a consequence of transient arousal.  J Dent Res. 82(4):284-288.

Katz J, Cohen L, Schmid R, et al. 2003.  Postoperative morphine use and hyperalgesia are reduced by preoperative but not intraoperative epidural analgesia: implications for preemptive analgesia and the prevention of central sensitization.  Anesthesiology 98(6):144-1460. 

Katz JD, Mamyrova G, Guzhva O et al. 2010. Gender bias in diagnosing fibromyalgia. Gend Med. 7(1):19-27. “This study provides insight into the diagnostic thought processes of rheumatologists. A minority of practitioners relied solely on the published ACR classification criteria for the diagnosis of FM. We also report gender bias with regard to disease classification, because rheumatologists were more likely to require a physical finding to support a diagnostic conclusion in male patients.” [It comes as no surprise that many physicians in general still expect more male patients to have a “real” reason for their symptoms. DJS]

Katz RS. P956: Learning disability in fibromyalgia patients: FMS patients report more language and spatial difficulties. Presented at: American College of Rheumatology 2012 Annual Meeting; Nov 10-14, Washington. Fibromyalgia patients report more learning disability symptoms than patients with rheumatoid arthritis. Patients with FM, RA, systemic lupus erythematosus and healthy controls were compared in a survey of reading, writing, body awareness/spatial relationships and oral expressive language. Patients with FM had worse reading and oral expressive language scores than controls, and worse scores in all areas than RA and SLE groups. They made mistakes such as skipping words or lines; in remembering what they read; understanding the main concept or details of the story; in grammar or punctuation; with tendency to be clumsy or uncoordinated; with hand-eye coordination; in finding the right words to say in a conversation; or in getting to the point of a conversation. This can make it very challenging to learn, especially in a school situation, or in a job. [This can make life difficult in general. It is good to understand that this is part of the problem. The spatial manifestations may be part of the use if the alternate kynurenine metabolic pathway and quinolinic acid production in FM. The clumsiness and hand-eye coordination may be associated with myofascial trigger point proprioceptive concomitants. Patients were not screened for co-existing TrPs. DJS]

Katz RS, Heard AR, Mills M et al. 2004.  The prevalence and clinical impact of reported cognitive difficulties (fibrofog) in patients with rheumatic disease with and without fibromyalgia.  J Clin Rheumatol. 10(2):53-58.  “Memory decline and mental confusion were coupled more often in patients with FMS (50.9-8.8%).  Patients with FMS with this combination of cognitive problems reported more pain (76.0-45.4%), stiffness (79.7-43.7%), fatigue (79.6-52.6%) and disturbed sleep (59.2-36.6%) compared with patients with FMS with memory problems alone.  Patients with rheumatic disease substantially differ in cognitive vulnerability, with patients with FMS at considerably higher risk for cognitive difficulty.  More importantly, the prevalence of a combined disturbance in memory and mental clarity is high and closely associated with the perception of increased illness severity and diminished mental health in FMS.  That this linkage has the possibility of having a great deal to do with an important clinical variant of FMS underscores the need for greater clinical recognition of this underrecognized pattern and for further research.”

Kaufman MB, Choy M. 2012. Pregabalin and simvastatin: first report of a case of rhabdomyolysis. P T. 37(10):579-595. This study concerns a 70-year-old man who arrived at the emergency department with multiple conditions. He was taking multiple medications. His rhabdomyolysis was found to be caused by simvastatin and perhaps also pregabalin. "It is not well known that pregabalin can cause rhabdomyolysis, and there is only one published report on pregabalin-induced hepatotoxicity. When different therapies are combined, the risk of rhabdomyolysis may be increased. The cause of rhabdomyolysis in our patient might be related to decreased renal elimination of both pregabalin and simvastatin (e.g., renal tubular reabsorption). It is important to be aware of this potentially serious and possibly life-threatening reaction especially when medication doses are increased or combined with other agents with similar safety issues."

Kaufmann, H. 1997. Neurally mediated syncope and syncope due to autonomic failure: differences and similarities.  J Clin Neurophysiol 14(3):183-196.

Kavadar G, Caglar N, Ozen S et al. 2015. Efficacy of conventional ultrasound therapy on myofascial pain syndrome: a placebo controlled study. 27(4):190-196. "Myofascial pain syndrome (MPS) is a complex pain syndrome characterized with trigger points (TP) in skeletal muscles…. Our results revealed that US treatment is effective on MPS." Free Article

Kavlock, R. J.  1999.  Overview of endocrine disruptor research activity in the United States. Chemosphere 39(8):1227-36.

Kay, G.G. and A. G. Harris.  1999.  Loratadine [Note: Claritin]: a non-sedating antihistamine. Review of its effects on cognition, psychomotor performance, mood and sedation.  Clin Exp Allergy 29(S3):147-150.

Kaya A, Akggl G, Gulkesen A et al. 2017. Cerebral blood flow volume using color duplex sonography in patients with fibromyalgia syndrome. Arch Rheumatol. 33(1):66-72. "Cerebral blood flow volume, ICA flow, and VA flow do not appear to increase, and are correlated with only Symptom Severity Scale among other clinical parameters reflecting disease severity in patients with FMS."

Kaya A, Kamanii A, Ardicoglu O et al. 2009.  Direct current therapy with/without lidocaine iontophoresis in myofascial pain syndrome.  Bratisi Lek Listy 110(3):185-191.  “Direct current therapy with/without lidocaine iontophoresis were determined to be effective treatment modalities in TrP management.”   [It would be interesting to see how patients with more than a few TrPs reacted to this method of treatment.  Is it possible to treat body-wide TrPs with this sort of therapy? DJS]

Kaya S, Hermans L, Willems T et al. 2013. Central sensitization in urogynecological chronic pelvic pain: a systematic literature review. Pain Physician. 16(4):291-308. "Although the majority of the literature provides evidence for the presence of CS (central sensitization) in urogynecological CPP (chronic pelvic pain) with changes in brain morphology/function and sensory function, it is unclear whether these changes in central pain processing are secondary or primary to CPP, especially since evidence regarding the function of endogenous pain inhibition and the role of psychosocial pain facilitation is scarce. Further studies with good methodological quality are needed in order to clarify exact mechanisms."

Kearns G, Gilbert KK, Allen B et al. 2018. Accuracy and safety of dry needle placement in the piriformis muscle in cadavers. J Man Manip Ther. 26(2):89-96. "A physical therapist was able to use bony landmark palpation to locate the piriformis muscle and use estimated adipose tissue thickness to choose a sufficient needle length to reach the medial third of the piriformis muscle. While the needle placement technique was safe and no sciatic nerve puncture occurred, the proximity of the piriformis muscle to the sciatic nerve warrants caution during needle placement."

Keitel, W. 1999. [ No title available] Fortschr Med 117(5):32-6. [German]

Kelly A, Khan K. 2008. Prevalence of allergies in children with complex medical problems. Clin Pediatr. 47(8):809-816. "The authors report a higher than expected prevalence of allergic and immune abnormalities in children with complex medical problems." [We must be attentive to the possibility of co-existing conditions in children with FM or CMP. DJS]

Kelly G.S. 2000. Insulin resistance: lifestyle and nutritional interventions. Altern Med Rev 5(2):109-32. Insulin resistance seems to be common and contributes to several frequent health problems including sleep apnea, obesity, and type 2 diabetes.  Possible perpetuating factors include diet, exercise, smoking and stress.

Kemeny, M. E. and T. L. Gruenewald.  1999.  Psychoneuroimmunology update.  Semin Gastrointest Dis 10(1):20-9.

Kempermann G, Neumann H. 2003.  Neuroscience.  Microglia: the enemy within?  Science 302(5651):1689-1690.  Microglia "...may be central players in repairing brain tissue and maintaining its integrity...and also...contribute to the rearrangement of neural connections and hence to the plasticity of normal brain tissue."  [Microglia may be part of the cause and the cure of central sensitization. DJS]

Kendall, SA, Henriksson, KG, Hurtig, I et al. 2003.  Differences in sensory thresholds in the skin of women with fibromyalgia syndrome: a comparison between ketamine responders and ketamine non-responders.  J Muscoloskel Pain 11(2):3-9.  This is another study indicating that subsets of patients with FMS have different pain processing dysfunctions. 

Kern, W., E. F. Stange, H. L. Fehm and H. H. Klein.  1999. [No title available].  Z Gastroenterol Suppl 1 (13):36-42 [German]. 

Kerns RD, Rosenberg R. 2000.  Predicting responses to self-management treatments for chronic pain: application of the pain stages of change model.  Pain 84(1):49-55.  “These findings suggest that increased commitment to a self-management approach to chronic pain may serve as a mediator or moderator of successful treatment.”

Kerr CE, Shaw JR, Wasserman RH et al. 2008. Tactile acuity in experienced Tai Chi practitioners: evidence for use dependent plasticity as an effect of sensory-attentional training. Exp Brain Res. 188(2):317-322. [Practitioners of t'ai chi had greater spatial acuity than controls. T'ai chi may be valuable in patients with proprioceptive dysfunction due to myofascial trigger points or FM. DJS]

Keskindag B, Karaaziz M. 2017. The association between pain and sleep in fibromyalgia. Saudi Med J. 38(5):465-475. "In total, 16 quantitative studies fulfilled the inclusion criteria. According to the results, increased pain in fibromyalgia was associated with reduced sleep quality, efficiency, and duration and increased sleep disturbance and onset latency and total wake time. Remarkably, depressive symptoms were also related to both pain and sleep in patients with fibromyalgia….Management strategies should be developed to decrease pain while increasing sleep quality in patients with fibromyalgia."

Khaki AM. 2006.  Pain clinic experience in a teaching hospital in Western Saudi Arabia.  Relationship of patient’s age and gender to various types of pain.  Saudi Med J. 27(12):1882-1886.  “Various types of chronic pain managed in the pain clinic (required) full understanding of pain neurophysiology as well as familiarity with contributing factors to the prevalence of pain.”

Khalsa PS. 2004. Biomechanics of musculoskeletal pain: dynamics of the neuromatrix.  J Electromyogr Kinesiol. 14(1):109-120.  “Mammals in general, and humans in particular, have evolved a highly sophisticated system of pain perception, which is characterized in humans by complementary but distinct neural processing of the intensity and location of a noxious stimulus, and a motivational/emotional or affective response to the stimulus.  The peripheral and central neurons that comprise this system, which has been called the 'neuromatrix', dynamically (temporally) respond and adapt to noxious biomechanical stimuli.  However, phenotypic variability of the neuromatrix can be large, which can result in a host of musculoskeletal conditions that are characterized by altered pain perception, which can and often does alter the course of the condition.  This neural plasticity has been well recognized in the central nervous system, but it has only more recently become known that peripheral nociceptors also adapt to their altered extracellular matrix environment.  This work reviews the biomechanics of pain focusing on the relevant stimulus that initiates responses by nociceptors to the cognitive perception of pain.”  [It is becoming increasingly evident that each of us is indeed unique, including in response to medications and to just about everything else.  One size does not fit all, and, especially in complex medical conditions, tailoring the medications and therapies to the individual is vital to success. DJS]

Khan MA, Lichtensteiger CA, Faroon O, Mumtaz M, Schaeffer DJ, Hansen LG. The hypothalamo-pituitary-thyroid (HPT) axis: a target of nonpersistent ortho-substituted PCB congeners.2002. Toxicol Sci Jan;65(1):52-61.

Kharkevich, D. A. and V. V. Churukanov.  1999.  Pharmacological regulation of descending cortical control of the nociceptive processing.  Eur J Pharmacol 375(1-3):121-31.

Khasar SG, Dina OA, Green PG et al. 2009.  Sound stress-induced long-term enhancement of mechanical hyperalgesia in rats is maintained by sympathoadrenal catecholamines.  J Pain. [Jul 1 Epub ahead of print].  “We present data showing mechanical hyperalgesia persisting for up to 28 days after exposure to sound stress, with evidence that the sympathoadrenal axis mediator epinephrine plays a major role.  These findings could have clinical implications with regard to novel potential treatments for chronic widespread pain syndromes, such as fibromyalgia.”  As many of us with FM know, noise can create a major stressor to the central nervous system.  This article provides some proof, and an indication of how long the effects can last.

Kho JY, Gaspar MP, Kane PM et al. 2017. Prognostic variables for patient return-to-work interval following carpal tunnel release in a Workers' Compensation population. Hand (N Y). 12(3):246-251. "WC (workers' compensation) patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW (return to work) following CTR (carpal tunnel release surgery) than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period."

Khoonsari PE, Musunri S, Herman S et al. 2018. Systematic analysis of the cerebrospinal fluid proteome of fibromyalgia patients. J Proteomics. [Apr 12 Epub ahead of print] "Currently, there are no biomarkers for FM, and the diagnosis is made subjectively by the clinicians. We have performed shotgun proteomics on cerebrospinal fluid (CSF) from FM patients and non-pain controls to find potential biomarker candidates for this syndrome. Based on our multivariate and univariate analyses, we found that the relative differences in the CSF proteome between FM patients and controls were moderate. Four proteins, important to discriminate FM patients from non-pain controls, were found: Apolipoprotein C-III, Galectin-3-binding protein, Malate dehydrogenase cytoplasmic and the neuropeptide precursor protein ProSAAS. These proteins are involved in lipoprotein lipase (LPL) activity, inflammatory signaling, energy metabolism and neuropeptide signaling....Fibromyalgia is present in as much as 2% of the population, causing pain, stiffness, and tenderness of the muscles. Upon accurate diagnostic, nonpharmacological and pharmacological therapies can be used to alleviate pain and manage other symptoms. However, lack of objective, universal applicable diagnostic criteria as well as vague and diffused symptoms, have made diagnosis difficult. In this context, our findings can shed light on potential value of CSF proteome for objectively diagnosing FM." [These patients are not screened for TrPs. DJS]

Kidd, P. M.  1999.  A review of nutrients and botanicals in the integrative management of cognitive dysfunction.  Altern Med Rev 4(3);144-61.

Kiers H 1, van Dieën JH, Brumagne S et al. 2014. Postural sway and integration of proprioceptive signals in subjects with LBP. Hum Mov Sci. 39C:109-120. "Patients with non-specific low back pain (LBP) may use postural control strategies that differ from healthy subjects….This model suggests that subjects with LBP use more co-contraction and less cognitive control, to maintain a standing balance when compared to subjects without LBP. In addition, a reduced weighting of proprioceptive signals in subjects with LBP is suggested as an explanation for the findings in this study."

Kietrys DM, Palombaro KM, Mannheimer JS. 2014. Dry needling for management of pain in the upper quarter and craniofacial region. Curr Pain Headache Rep. 18(8):437. "For patients with upper quarter myofascial pain, a 2013 systematic review and meta-analysis of 12 randomized controlled studies reported that dry needling is effective in reducing pain (especially immediately after treatment) in patients with upper quarter pain. There have been fewer studies of patients with craniofacial pain and myofascial pain in other regions, but most of these studies report findings to suggest the dry needling may be helpful in reducing pain and improving other pain related variables such as the pain pressure threshold. More rigorous randomized controlled trials are clearly needed to more fully elucidate the effectiveness of dry needling."

Kifer T, Misak Z, Jadresin O et al. 2017. Anterior cutaneous nerve entrapment syndrome in children - Prospective observational study. Clin J Pain. [Nov 17 Epub ahead of print] "Anterior cutaneous nerve entrapment syndrome (ACNES) is often an overlooked cause of abdominal pain.... All children were treated by ultrasound guided subfascial injection of 40 mg 1% lidocaine and 4 mg dexamethasone into the rectus abdominis muscle in the place of the most severe pain (trigger point infiltration)....The study included 38 children (28, 73.7% female; median age 15 y). The majority of patients had pain in the lower right abdominal quadrant and were diagnosed in a median of 6 (range: 0.5 to 50) months after symptoms started. Overall, 24 (63%) patients achieved sustained symptom-free remission after a median of 1...trigger point infiltrations during the first treatment session. Five (13%) children were surgically treated due to a lack of long-term response. Children who were surgically treated required a higher number of block applications during the first session of treatment, compared to children who were successfully treated conservatively."

Kim CH, Vincent A, Clauw DJ et al. 2013. Association between alcohol consumption and symptom severity and quality of life in patients with fibromyalgia. Arthritis Res Ther. 15(2):R42. "Our study demonstrates that low and moderate alcohol consumption was associated with lower fibromyalgia symptoms and better quality of life (QOL) compared to no alcohol consumption. The reasons for these results are unclear. Since recent studies have demonstrated that gamma-Aminobutyric Acid (GABA) levels are low in fibromyalgia, and alcohol is known to be a GABA-agonist, future studies should examine whether alcohol could have a salutary effect on pain and other symptoms in fibromyalgia."

Kim DH, Yoon DM, Yoon KB. 2015. The effects of myofascial trigger point injections on nocturnal calf cramps. J Am Board Fam Med. 28(1):21-27. "The purpose of this study was to elucidate the effects of injection at trigger points on pain and sleep disturbance in patients with nocturnal calf cramps (NCCs)…. Patients with NCCs that occurred at least once per week and who had myofascial trigger points (MTrPs) on the gastrocnemius muscles were enrolled in the study for 9 months…. These preliminary data show that injection at MTrPs in patients with NCCs not only alleviated pain and reduced the frequency of cramps but also lessened the severity of insomnia as measured by the ISI. A larger randomized controlled trial is needed to confirm these findings and determine whether the effect lasts over the long term." Free Article

Kim DS, Jeong TY, Kim YK 2013. Usefulness of a myofascial trigger point injection for groin pain in patients with chronic prostatitis/chronic pelvic pain syndrome: a pilot study. Arch Phys Med Rehab 94(5):930-936. "in patients with CP/CPPS, US-guided trigger point injections of the iliopsoas, hip adductor, and abdominal muscles are safe and effective for both diagnosis and treatment when the cause of groin pain is suspected to originate in from muscles. In particular, the iliopsoas muscle was affected in all patients (N=21) in this study.

Kim HA, Hwang UJ, Jung SH et al. 2017. Comparison of shoulder strength in males with and without myofascial trigger points in the upper trapezius. Clin Biomech (Bristol, Avon). 49:134-138. "These findings suggest that decreased strength in the shoulder abductor with restricted scapular elevation should be considered in evaluating and treating individuals with myofascial trigger points of the upper trapezius."

Kim J, Grobelna A. (Editors) Nabilone for Chronic Pain Management: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Aug. CADTH Rapid Response Reports. Excerpt: "People with diseases that were once considered generally fatal, such as cancer and HIV/AIDS, are now surviving their acute illness with an increased quantity of life. However, in many cases, a poor quality of life (QoL) ensues due to chronic pain caused by persisting illness, ongoing treatment, or lasting damage after resolution or cure of the disease. Chronic pain, also caused by many other conditions, such as fibromyalgia, multiple sclerosis (MS), and neuropathy, is difficult to treat, a major contributor to time away from work, and associated with increased risk of suicide."

Kim MH, Nahm FS, Kim TK et al. 2013. Comparison of postoperative pain in the first and second knee in staged bilateral total knee arthroplasty: clinical evidence of enhanced pain sensitivity following surgical injury. Pain. [Aug 29 Epub ahead of print]. "Staged bilateral total knee arthroplasty (TKA) may provide an ideal clinical model for the study of central sensitization. In staged TKA, hyperalgesia may be induced due to repeated surgical injury possibly via central sensitization, which can decrease functional outcomes. Therefore, we hypothesized that in staged bilateral TKA, patients would have greater pain in the second operated knee than in the first." This study confirmed that hypothesis. "…patients undergoing staged bilateral TKA suffer greater postoperative pain in the second operated knee than the first. This suggests extension of hyperalgesia beyond the initially injured site to remote regions following surgical injury, in which central sensitization may be involved. Therapeutic approaches to reduce such hyperalgesia induced in the course of staged operations are required."

Kim PS. 2002. Role of injection therapy: review of indications for trigger point injections, regional blocks, facet joint injections, and intra-articular injections. Curr Opin Rheumatol Jan;14(1):52-7. Multidiciplinary therapies for many chronic pain patients may often include injection therapies as part of effective pain management.

Kim SA, Oh KY, Choi WH et al. 2013. Ischemic compression after trigger point injection affect the treatment of myofascial trigger points. Ann Rehabil Med. 37(4):541-546. This team from Soonchunhyang University College of Medicine in Korea divided 60 patients with active TrPs into 3 groups. Group 1 received trigger point injections only, group 2 received TrP injections with 30 seconds of ischemic compression and group 3 received the TrP injections with 60 seconds of ischemic compression. Significant improvement was found in all groups, although the groups receiving the additional ischemic compression had more improvement, no matter the time of compression. "This study demonstrated the effectiveness of ischemic compression for myofascial trigger point. Trigger point injections combined with ischemic compression shows better effects on treatment of myofascial trigger points in the upper trapezius muscle than the only trigger point injections therapy. But the duration of ischemic compression did not affect treatment of myofascial trigger point."

Kim SC, Landon JE, Solomon DH. 2013. Clinical characteristics and medication uses among fibromyalgia patients newly prescribed amitriptyline, duloxetine, gabapentin or pregabalin. Arthritis Care Res (Hoboken). [Jul 16 Epub ahead of print]. "Fibromyalgia is a common chronic pain disorder with unclear etiology. No definitive treatment is available for fibromyalgia and treatment with antidepressants or antiepileptics is often used for symptom management …. Back pain was the most frequent comorbidity in all four groups (48%-64%) and hypertension, headache, depression, and sleep disorder were also common. Median daily dose at the start of follow-up was 25mg for amitriptyline, 60mg for duloxetine, 300mg for gabapentin, and 75mg for pregabalin and more than 60% of patients remained on the same dose throughout the follow-up period. Only one fifth of patients continued the treatment started for at least one year. The mean number of different prescription drugs at baseline ranged from 8 to 10 across the groups. More than a half of patients used opioids and a third used benzodiazepines, sleep disorder drugs and muscle relaxants….Patients who started one of the four common drugs for fibromyalgia similarly had multiple comorbidities and other fibromyalgia-related drug use, but continued the treatment only for a short time. The dose of the four drugs was not increased in most patients during the follow-up."

Kim SH. 2007.  Skin biopsy findings: implications for the pathophysiology of fibromyalgia.  Med Hypotheses [Jan 8 Epub ahead of print]  Skin abnormalities in FMS patients may be significant.

Kim SH, Kim DH, Yoon KB et al. 2013. Clinical effectiveness of the obturator externus muscle injection in chronic pelvic pain patients. Nov 5. [Epub ahead of print]. Obturator externus injection, in this study of 23 patients fluoroscopy-guided, reduced symptoms greatly, and may be "…a valuable therpeutic option for a select group of chronic pelvic patients who present with localized tenderness in the OE muscle that is accompanied by groin, antromedial thigh, or hip pain."

Kim SH, Kim SH, Kim SK et al. 2011. Spatial versus verbal memory impairments in patients with fibromyalgia. Rheumatol Int. [Jan 19 Epub ahead of print]. "Mounting evidence suggests that individuals with fibromyalgia (FM) have impairments in general cognitive functions. However, few studies have explored the possibility of dissociation between verbal and visulospatial memory impairments in FM. Therefore, the purpose of this study was to investigate the asymmetrical impairment of cognitive functions between verbal and visulospatial memory and between short-term and long-term memory. Neuropsychological assessments were carried out on 23 female patients with FM and 24 healthy female controls....These findings suggest that spatial memory abilities may be more impaired than verbal memory abilities in patients with FM."

Kim SH, Moon IS, Park IS. 2013. Unique hippocampal changes and allodynia in a model of chronic stress. J Korean Med Sci. 28(6):946-950. Chronic stress may bring about central sensitization and hippocampal changes in rats.

Kim SH, Won SJ, Mao XO et al. 2005.  Molecular mechanisms of cannabinoid protection from neuronal excitotoxicity.  Mol Pharmacol. [Nov 18 Epub ahead of print].  “Cannabinoids appear to protect neurons against NMDA toxicity at least partly by activation of CB1R and downstream inhibition of PKA signaling and NO generation.”

Kim SJ, Lee JH. 2018. Effects of sternocleidomastoid muscle and suboccipital muscle soft tissue release on muscle hardness and pressure pain of the sternocleidomastoid muscle and upper trapezius muscle in smartphone users with latent trigger points. Medicine (Baltimore). 97(36):e12133. "Few studies have been performed regarding the reduction of pain in the upper trapezius (UT) muscle by applying interventions to the sternocleidomastoid (SCM) muscle, which is innervated by the same nerves. The purpose of this study was to investigate the effects of soft tissue release intervention on the SCM and suboccipital muscles with regard to muscle hardness and pressure pain threshold (PPT) of the SCM and UT muscles in smartphone users with latent myofascial trigger points (MTrPs) in the UT muscle. Seventeen smartphone users (5 men and 12 women) with latent MTrPs in the UT muscle participated in the study. This study used a single blinding, cross-over design, wherein sternocleidomastoid soft tissue release (SSTR) and suboccipital release (SR) were applied on the subjects in random order one week apart. Muscle hardness and the PPT of the SCM and UT muscles were assessed before and after the intervention. After SSTR was applied, the SCM and UT muscles showed a significant decrease in muscle hardness and a significant increase in PPT. After SR was applied, the UT muscle showed a significant decrease in muscle hardness and a significant increase in PPT. When comparing the amount of change between the SSTR and SR interventions, significant differences were found for SCM muscle hardness and PPT of the UT muscle in the SSTR intervention, compared with the SR intervention.Therefore, we suggest that, to reduce pain in the UT muscle, it may be useful to apply intervention directly to the UT muscle, as well as to the SCM muscle, which is innervated by the same nerve."

Kim Y, Yang HR, Lee JW et al. 2014. Effects of the high-power pain threshold ultrasound technique in the elderly with latent myofascial trigger points: a double-blind randomized study. J Back Musculoskelet Rehabil. 27(1):17-23. "The high-power pain threshold ultrasound (HPPTUS) technique has been introduced as a novel treatment method in patients with myofascial trigger points (MTrPs)…. The results indicate that the HPPTUS technique in same manner as treatment of active MTrPs is not superior to the conventional ultrasound technique in the treatment of the elderly patients with the latent MTrPs."

Kimmelberg H.K., Zhou M. 2002.  Hippocampal astrocytes show heterogeneity of swelling activated anion currents.  Glia (Suppl 1):S55 [Abstract]. 

Kindler LL, Bennett RM, Jones KD. 2011. Central sensitivity syndromes: mounting pathophysiologic evidence to link fibromyalgia with other common chronic pain disorders. Pain Manag Nurs. 12(1):15-24. "'Central sensitivity syndromes' denotes an emerging nomenclature that could be embraced by researchers investigating each of these disorders. Moreover, a shared paradigm would be useful in promoting cross-fertilization between researchers. Scientists and clinicians could most effectively forward the understanding and treatment of fibromyalgia and other common chronic pain disorders through an appreciation of their shared pathophysiology."

King CD, Jastrowski Mano KE, Barnett KA et al. 2016. Pressure pain threshold and anxiety in adolescent females with and without juvenile fibromyalgia: A pilot study. Clin J Pain. [Nov 10 Epub ahead of print.] "Adolescents with JFM exhibited greater sensitivity to pressure pain compared to controls. While the difference between JFM and controls was only observed at the forehead, the intensity of pain produced by the pressure algometry at both sites was significantly higher in the JFM participants compared to controls. Correlations between clinical pain and anxiety were significant for the JFM group only. No relationships were observed between anxiety and pressure pain for either group…. This study is a first step towards investigating mechanisms of altered pain processing in adolescents with JFM. Adolescents with JFM were found to be more sensitive to pressure pain than their healthy peers, which suggests a propensity for sensitization of peripheral and/or central nociceptive information often reported in adult fibromyalgia, and which does not appear to be affected by anxiety.

King, D. E. and B. Bushwick.  1994.  Beliefs and attitudes of hospital inpatients about faith healing and prayer.  J Fam Pract 39(4):349-52.

Kirchheiner J, Brockmoller J. 2005.  Clinical consequences of cytochrome P450 2C9 polymorphisms.  Clin Pharmacol Ther. 77(1):1-16.   This is a good review of the current knowledge of the effects of genetic variations on drug metabolism.   Phenotyping has potential use indicating both potential drug effectiveness and potential toxicity, but the knowledge needs to be developed.

Kishi A, Natelson BH, Togo F et al. 2011. Sleep-stage dynamics in patients with chronic fatigue syndrome with or without fibromyalgia. SLEEP 34(11):1551-1560. Chronic fatigue syndrome (CFS) and fibromyalgia (FM) are medically unexplained conditions that often have overlapping symptoms, including sleep-related complaints. However, differences between the 2 conditions have been reported, and we hypothesized that dynamic aspects of sleep would be different in the 2 groups of patients....We studied transition probabilities and rates between sleep stages (waking, rapid eye movement [REM] sleep, stage 1 [S1], stage 2 [S2], and slow-wave sleep [SWS]) and duration distributions of each sleep stage. We found that the probability of transition from REM sleep to waking was significantly greater in subjects with CFS alone than in control subjects, which may be the specific sleep problem for people with CFS alone. Probabilities of (a) transitions from waking, REM sleep, and S1 to S2 and (b) those from SWS to waking and S1 were significantly greater in subjects with CFS+FM than in control subjects; in addition, rates of these transitions were also significantly increased in subjects with CFS+FM. Result (a) might indicate increased sleep pressure in subjects with CFS+FM whereas result (b) may be the specific sleep problem of subjects with CFS+FM. We also found that shorter durations of S2 sleep are specific to patients with CFS+FM, not to CFS alone....These results suggest that CFS and FM may be different illnesses associated with different problems of sleep regulation."

Kiso T, Moriyama A, Furutani M et al. 2018. Effects of pregabalin and duloxetine on neurotransmitters in the dorsal horn of the spinal cord in a rat model of fibromyalgia. Eur J Pharmacol. 827:117-124. "Dysfunction of the monoamine systems in the nervous system is associated with the clinical symptoms of fibromyalgia...While the levels of monoamines and glutamate were lower in the spinal cord of RIM (reserpine-induced myalgia) rats than in normal rats, levels of GABA did not markedly differ. Duloxetine increased the levels of all three monoamines in normal and RIM rats in a dose-dependent manner. In contrast, pregabalin only increased norepinephrine levels in RIM rats. These results indicate that while both pregabalin and duloxetine ameliorate muscle pressure thresholds in RIM rats, their effects on the levels of extracellular neurotransmitters in the spinal cord differ considerably."

Kissel CL, Kovács KJ, Larson AA. 2017. Evidence for the modulation of nociception in mice by central mast cells. Eur J Pain. [Jul 19 Epub ahead of print] "We tested the possibility that mast cells modulate nociception centrally, similar to their role in the periphery….We examined the central effect of two hyperalgesic compounds that induce mast cell degranulation and of stabilized mast cells using cromolyn." The results suggest that when localized mast cells degranulate, that sensitizes the central pain pathways and can cause central sensitization. Cromalyn, a mast cell stabilizer, blocks these effects in mice." [This may indicate that the loss of cellular granules found in healthy mast cells, such as found in mast cell dysfunctions (including allergies), may be sufficient to cause the central sensitization state of FM. DJS]

Kivimaki M, Leino-Arjas P, Kaila-Kangas L et al. 2006.  Increased sickness absence among employees with fibromyalgia.  Ann Rheum Dis June 22 [Epub ahead of print].  “FM is associated with a substantially increased risk of medically certified sickness absence...”

Klaver-Krol EG, Rasker JJ, Henriquez NR. 2012. Muscle fiber velocity and electromyographic signs of fatigue in fibromyalgia. Muscle Nerve. 46(5):738-745. "We investigated possible differences in surface electromyography (sEMG) in clinically unaffected muscle between patients with FM and controls....sEMG was performed on the biceps brachii muscle of 13 women with FM and 14 matched healthy controls during prolonged dynamic exercises, unloaded, and loaded up to 20% of maximum voluntary contraction. The sEMG parameters were: muscle fiber conduction velocity (CV); skewness of motor unit potential (peak) velocities; peak frequency (PF) (number of peaks per second); and average rectified voltage (ARV). Results: There was significantly higher CV in the FM group. Although the FM group performed the tests equally well, their electromyographic fatigue was significantly less expressed compared with controls (in CV, PF, and ARV)....In the patients with FM, we clearly showed functional abnormalities of the muscle membrane, which led to high conduction velocity and resistance to fatigue in electromyography. [It would be very interesting to check these patients for co-existing myofascial trigger points in those muscles. The unsuspected TrPs could be the actual cause of the symptoms noted. DJS]

Klaver-Krol EG, Zwarts MJ, Ten Klooster PM et al. 2012. Abnormal muscle membrane function in fibromyalgia patients and its relationship to the number of tender points. Clin Exp Rheumatol. [Nov 22 Epub ahead of print]. "Fibromyalgia (FM) is a disorder characterized by chronic widespread pain in soft tissues, especially in muscles. Previous research has demonstrated a higher muscle fibre conduction velocity (CV) in painful muscles of FM patients. The primary goal of this study was to investigate whether there is also a difference in CV in non-painful, non-tender point (TP) related muscles between FM patients and controls. The secondary goal was to explore associations between the CV, the number of TPs and the complaints in FM....The results demonstrate abnormally high muscle membrane conduction velocity in FM, even in non-TP muscles. In addition, a relationship has been found between the high membrane velocity and the number of TPs. [These authors considered tender points and trigger points to be the same. DJS]

Kleier DJ. 1985.  Referred pain from a myofascial trigger point mimicking pain of endodontic origin.  J Endod. 11(9):408-411.  [Many a healthy tooth has been mishandled due to TrPs that can refer pain and sensitivity to the teeth.  Dentists must learn myofascial pain to avoid harming patients. DJS]

Klekner A, Felszeghy S, Tammi R et al. 2005.  Quantitative determination of hyaluronan content in cerebral aneurysms by digital densitometry.  Zentralbl Neurochir. 66(4):207-212.  “Results suggest that an elevated hyaluronan level in the extracellular matrix may affect the cerebral arterial wall architecture.  It is reasonable to suppose that the increased hyaluronan content creates a viscoelastic ECM which might improve the biomechanical resistance of the thinned vessel wall.”  [This seemingly unrelated piece of research may provide clues to the higher viscosity of the extracellular matrix of a subset of patients with both FMS and CMP, especially in relation to the geloid mass.  DJS]

Knezevic NN, Tverdohleb T, Knezevic I et al. 2018. The role of genetic polymorphisms in chronic pain patients. Int J Mol Sci. 19(6). pii: E1707. "It is estimated that the total annual financial cost for pain management in the U.S. exceeds 100 billion dollars. However, when indirect costs are included, such as functional disability and reduction in working hours, the cost can reach more than 300 billion dollars. In chronic pain patients, the role of pharmacogenetics is determined by genetic effects on various pain types, as well as the genetic effect on drug safety and efficacy. In this review article, we discuss genetic polymorphisms present in different types of chronic pain, such as fibromyalgia, low back pain, migraine, painful peripheral diabetic neuropathy and trigeminal neuralgia. Furthermore, we discuss the role of CYP450 enzymes involved in metabolism of drugs, which have been used for treatment of chronic pain (amitriptyline, duloxetine, opioids, etc.). We also discuss how pharmacogenetics can be applied towards improving drug efficacy, shortening the time required to achieve therapeutic outcomes, reducing risks of side effects, and reducing medical costs and reliance upon polypharmacy."

Knezevic NN, Tverdohleb T, Nikibin F. 2017. Management of chronic neuropathic pain with single and compounded topical analgesics. Pain Manag. 7(6):537-558. "The goal of our review was to emphasize important aspects that physicians should take into consideration when prescribing topical analgesics as part of chronic neuropathic pain treatment. We discuss the dermatopharmacokinetics and microstructural components of the skin, differences between topical and transdermal drug delivery, and topical medication effects on peripheral neuropathy and central sensitization. Even though the US FDA approved topical analgesics are 8%-capsaicin and 5%-lidocaine patches for treating postherpetic neuralgia, there are many other studies conducted on the efficacy of topical ketamine cream, clonidine gel, topical gabapentin, topical baclofen and topical phenytoin for peripheral neuropathic pain, either alone or in combination with other formulations. Furthermore, we discuss new compounded topical analgesics that are becoming more popular and that are showing promising results in the management of chronic peripheral neuropathies. However, more studies are needed for elucidation of the role of topical analgesics and their effects, especially when combined with other treatments."

Knockaert DC, D’Heygere FG, Bobbaers HJ. 1989.  Ilioinguinal nerve entrapment: a little-known cause of iliac fossa pain.  Postgrad Med J. 65(767):632-635.  “The ilioinguinal nerve entrapment syndrome is an abdominal muscular pain syndrome, characterized by the clinical triad of muscular type iliac fossa pain with a characteristic radiation pattern, an altered sensory perception in the ilioinguinal nerve cutaneous innervation area, and a well-circumscribed trigger point medial and below the anterosuperior iliac spine.  Relief of pain by infiltration of a local anaesthetic confirms the diagnosis.  This report describes retrospectively the clinical picture of ilioinguinal nerve entrapment in 32 mainly non-surgical patients.  In 14 cases a definite diagnosis was established and in 18 patients the diagnosis was considered probable.  The mean delay in diagnosis was 12.8 months. Better knowledge of this syndrome may avoid invasive investigations and be cost saving.”

Ko EJ, Jeon JY, Kim W et al. 2016. Referred symptom from myofascial pain syndrome: One of the most important causes of sensory disturbance in breast cancer patients using taxanes. Eur J Cancer Care (Engl). [Dec 2 Epub ahead of print.] "When breast cancer patients complain of upper extremity sensory disturbance, various causes, especially referred symptom from MPS, should be considered for effective treatment."

Ko GD, Bober SL, Mindra S et al. 2016. Medical cannabis - the Canadian perspective. J Pain Res. 9:735-744. "Cannabis has been widely used as a medicinal agent in Eastern medicine with earliest evidence in ancient Chinese practice dating back to 2700 BC. Over time, the use of medical cannabis has been increasingly adopted by Western medicine and is thus a rapidly emerging field that all pain physicians need to be aware of. Several randomized controlled trials have shown a significant and dose-dependent relationship between neuropathic pain relief and tetrahydrocannabinol - the principal psychoactive component of cannabis. Despite this, barriers exist to use from both the patient perspective (cost, addiction, social stigma, lack of understanding regarding safe administration) and the physician perspective (credibility, criminality, clinical evidence, patient addiction, and policy from the governing medical colleges). This review addresses these barriers and draws attention to key concerns in the Canadian medical system, providing updated treatment approaches to help clinicians work with their patients in achieving adequate pain control, reduced narcotic medication use, and enhanced quality of life. This review also includes case studies demonstrating the use of medical marijuana by patients with neuropathic low-back pain, neuropathic pain in fibromyalgia, and neuropathic pain in multiple sclerosis. While significant preclinical data have demonstrated the potential therapeutic benefits of cannabis for treating pain in osteoarthritis, rheumatoid arthritis, fibromyalgia, and cancer, further studies are needed with randomized controlled trials and larger study populations to identify the specific strains and concentrations that will work best with selected cohorts." Free PMC Article

Ko GD, Nowacki NB, Arseneau L et al. 2010. Omega-3 fatty acids for neuropathic pain: case series. Clin J Pain. 26(2):168-172.  “Objective: The aim of this case series study was to investigate and report on patients with neuropathic pain who responded to treatment with omega-3 fatty acids. Methods: Five patients with different underlying diagnoses including cervical radiculopathy, thoracic outlet syndrome, fibromyalgia, carpal tunnel syndrome, burn injury were treated with high oral doses of omega 3 fish oil (varying from 2400-7200 mg/day of EPA-DHA). This first-ever reported case series suggests that omega-3 fatty acids may be of benefit in the management of patients with neuropathic pain.”    

Kobesova A, Lewit K. 2000.  A case of a pathogenic active scar.  Australas Chiropr Osteopathy. 9(1):17-19.  Scars are like icebergs.  Their surface is only a small indication of the amount of disruption that they can be causing.  The example is an appendectomy scar in a person with abdominal and low back pain.  Extensive and expensive testing remained negative, and the pain persisted.  When the scar was treated with barrier release mobilizing the tissue and treating related TrPs, the symptoms were relieved.

Kobesova A, Morris CE, Lewit K et al. 2007. Twenty-year-old pathogenic “active” postsurgical scar: a case study of a patient with persistent right lower quadrant pain.  J Manipulative Physiol Ther. 30(3):234-238.  Even after decades without adequate diagnosis and treatment, trigger points in scar tissue may be effectively treated with tissue mobilization.  [This gives pain patients hope, but also leads one to wonder how many people are living with unnecessary pain. DJS]

Koblish M, Carr R, Siuda ER. 2017. TRV0109101, a G protein-biased agonist of the μ-opioid receptor, does not promote opioid-induced mechanical allodynia following chronic administration. J Pharmacol Exp Ther. [May 22 Epub ahead of print] Chronic opioid use can cause an increase in central sensitization and tolerance requiring increased dose need for the same effect, as well as many side-effects, but currently are the best pain relievers we have. A potential new pain reliever does not cause opioid induced hyperalgesia and allodynia in mice. A relative of oliceridine was studied. "TRV0109101 was able to rapidly reverse allodynia. This gives us hope that a whole new type of medication may someday be available to help chronic pain patients, but much more research needs to be done."

Koca I, Tutoglu A, Boyacı A. 2014. An evaluation of oxidative stress and antioxidant capacity in patients with myofascial pain syndrome. Mod Rheumatol. 24(6):992-996. "The results of this study determined that the oxidant/antioxidant balance was impaired in MPS patients and thus MPS can be considered to be related to an increase in oxidative stress." [This is consistent with the myofascial trigger points as areas in energy crisis. DJS]

Koca I, Tutoglu A, Boyacı A et al. 2013. A comparison of the effectiveness of low-, moderate- and high-dose ultrasound therapy applied in the treatment of myofascial pain syndrome. Mod Rheumatol. [Dec 11 Epub ahead of print.] "This study aimed to compare and evaluate the effects of ultrasound (US) treatment applied at low-, medium- and high-power-pain threshold (HPPT) doses to trigger points in the treatment of myofascial pain syndrome (MPS). Methods: The study comprised 61 (40 female and 21 male) patients diagnosed with MPS, aged between 18 and 60 years. The patients were randomly allocated to three groups for the US application at different dosages. Group I patients received treatment of medium-dose US (1.5 Watt/cm2), Group II received HPPT US, and Group III received low-dose US (0.5 W/cm2). The patients were evaluated pre-treatment and 3 weeks after treatment in respect of visual analogue scale (VAS) scores, number of trigger points (NTP), pressure pain threshold (PPT), Range of Tragus-Acromioclavicular joint (RT-AJ) and neck pain disability scores (NPDS). Results: A significant improvement was determined after treatment in all scores except PPT in Group I, in all scores in Group II, and only in the VAS score in Group III. When the groups were compared post-treatment in respect of improvement in NTP, VAS, RT-AJ and NPDS scores, Group II showed significant superiority over Group I, and Group I was determined to have significant superiority over Group III in respect of VAS, RT-AJ and NPDS scores (p < 0.05).… In the treatment of MPS, US therapy at HPPT dose can be considered as an alternative therapy method, which is more economical and more effective than low-dose and conventional US therapy."

Koca TT, Karaca Acet G, Tanr?kut E et al. 2016. Evaluation of sleep disorder and its effect on sexual dysfunction in patients with fibromyalgia syndrome. Turk J Obstet Gynecol. 13(4):167-171. "Sleep disorder is regarded as the underlying cause for many signs and symptoms in FMS. Sexual dysfunction may develop in women with FMS, based on the severity of the disease and poor sleep quality. We found that sleep dysfunction was significantly related with the severity of disease, pain, and sexual dysfunction." Free Article

Koca TT, Seyithanoglu M, Sagiroglu S et al. 2018. Frequency of audiological complaints in patients with fibromyalgia syndrome and its relationship with oxidative stress. Niger J Clin Pract. 21(10):1271-1277. "Central sensitization-related neuroaudiological symptoms are frequently seen in patients with fibromyalgia syndrome (FMS). This study aimed to evaluate the audiological signs and symptoms in patients with FMS and explore their relationship with oxidative stress markers.... Patients with FMS have high levels of oxidative stress markers (GPx, NO, and MDA), highly frequent audiological symptoms with high hearing frequencies in audiometry, independent of disease severity."

Kodama Y, Seo K, Hayashi T et al. 2012. Orofacial pain related to traumatic neuroma in a patient with multiple TMJ operations. Cranio. 30(3):183-187. "The diagnosis of orofacial pain associated with temporomandibular disorders after repeated temporomandibular joint (TMJ) surgeries can be quite difficult. This case report describes a 52-year-old woman who had previously undergone five TMJ surgeries and developed divergent pain caused by a trigger point in the left preauricular area. Computed tomography and magnetic resonance imaging could not be used to identify a lesion because of metallic artifacts from a TMJ prosthesis. However, sonography indicated the location of the suspected lesion. Moreover, a neurological examination performed with local anesthesia was clinically effective in ruling out other diagnoses of orofacial pain. Ultimately, a histopathological examination of a biopsy specimen from the painful site confirmed the lesion to be a traumatic neuroma. This case report suggests the value of including traumatic neuroma in the differential diagnosis of patients with a history of previous TMJ surgery who present with orofacial pain in the region of the TMJ."

Kojima C, Fujishima I, Ohkuma R et al. 2002.  Jaw opening and swallow triggering method for bilateral-brain-damaged patients: K-point stimulation.  Dysphagia. 17(4):273-277.  “The trigger point lies on the mucosa lateral to the palatoglossal arch and medial to the pterygomandibular fold at the height of the postretromolar pad.”  “Stimulating the trigger point was useful for opening the mouth and facilitating swallowing in pseudobulbar palsy patients and that this technique may be of help in these patients in terms of oral health care and feeding.”

Kohlmann T. 2003.  [Musculoskeletal pain in the population] [German]  Schmerz. 17(6):405-411.  This review indicates that about 16% of the German population has severe musculoskeletal pain.

Kojic Z, Stojanovic D. 2013. Pathophysiology of migraine--from molecular to personalized medicine. Med Pregl. 66(1-2):53-57. "Understanding of migraine pathophysiology has substantially improved over the last two decades. As a result, migraine is now mainly considered to be a disorder of the brain, rather than one of the vasculature or the meninges....Although it remains speculative how exactly they relate to each other, the following three processes are important in migraine: 1. Cortical spreading depression is a wave of intense depolarization, it starts in the occipital lobe, propagates through the brain and is followed by a period of suppressed activity. 2. Activation of the trigemonovascular system causes the release of neuropeptides (e.g. calcitonin gene-related peptide, substance P) from the peripheral trigeminal nerve endings. These neuropeptides are thought to play a role in causing and maintaining headache. 3. Sensitization of peripheral and central brain areas, it is thought that pulsating quality of migraine headache is caused by a process of peripheral sensitization. Cutaneous allodynia is a marker of central sensitization....The view that the aura is caused by cortical spreading depression has become generally accepted, and the same is true for the view that activation of the trigemonovascular system underlies migraine headache. However, the relationship between the aura and the activation of the trigemonovascular system and the start of headache remains elusive....One of the most important aspects of the pathophysiology of migraine is the hereditary nature of the disorder....Identification of polymorphisms and genetic biomarkers should help us to understand migraine pathophysiology better and thus enable the development of specific, effective 'individually-tailored treatment' for each particular migraine patient (personalized medicine)."

Kolar P, Sulc J, Kynci M et al. 2010. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol. 109(4):1064-1071. "Significant involvement of the diaphragm in the limb postural activities was found." [The implications are that contractured muscles due to myofascial TrPs can significantly impair breathing. DJS]

Kole AK, Roy R, Kole DC. 2013. Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis. 34(2):107-112. "Musculoskeletal involvement was common in HIV patients causing increased morbidity, so early detection and timely intervention is essential to improve quality of life."

Komaroff, A. L. and D. S. Buchwald.  1998.  Chronic fatigue syndrome: an update.  Annu Rev Med 49:1-13.  

Konczak J, Abbruzzese G. 2013. Focal dystonia in musicians: linking motor symptoms to somatosensory dysfunction. Front Hum Neurosci. 7:297. "Musician's dystonia (MD) is a neurological motor disorder characterized by involuntary contractions of those muscles involved in the play of a musical instrument. It is task-specific and initially only impairs the voluntary control of highly practiced musical motor skills. MD can lead to a severe decrement in a musician's ability to perform. While the etiology and the neurological pathomechanism of the disease remain unknown, it is known that MD like others forms of focal dystonia is associated with somatosensory deficits, specifically a decreased precision of tactile and proprioceptive perception. The sensory component of the disease becomes also evident by the patients' use of "sensory tricks" such as touching dystonic muscles to alleviate motor symptoms. The central premise of this paper is that the motor symptoms of MD have a somatosensory origin and are not fully explained as a problem of motor execution. We outline how altered proprioceptive feedback ultimately leads to a loss of voluntary motor control and propose two scenarios that explain why sensory tricks are effective. They are effective, because the sensorimotor system either recruits neural resources normally involved in tactile-proprioceptive (sensory) integration, or utilizes a fully functioning motor efference copy mechanism to align experienced with expected sensory feedback. We argue that an enhanced understanding of how a primary sensory deficit interacts with mechanisms of sensorimotor integration in MD provides helpful insights for the design of more effective behavioral therapies. "[Myofascial trigger points can and do cause the symptoms here described, but are not mentioned in this study. DJS]

Kong J, Wolcott E, Wang Z et al. 2018. Altered resting state functional connectivity of the cognitive control network in fibromyalgia and the modulation effect of mind-body intervention. Brain Imaging Behav. [May 2 Epub ahead of print] "This study examines altered resting state functional connectivity (rsFC) of the cognitive control network (CCN) in fibromyalgia patients as compared to healthy controls, as well as how an effective mind-body intervention, Tai Chi, can modulate the altered rsFC of the CCN. Patients with fibromyalgia and matched healthy subjects were recruited in this study. Fibromyalgia patients were scanned 12 weeks before and after intervention.... Compared to healthy subjects, FM patients showed a significant change in resting state functional connectivity that correlated with clinical improvements. "This rsFC change was also significantly associated with corresponding changes in the Overall Impact domain of the Revised Fibromyalgia Impact Questionnaire (FIQR)."

Kong WM, Mohamed Z, Alshawsh MA et al. 2017. Evaluation of pharmacokinetics and blood-brain barrier permeability of mitragynine using in vivo microdialysis technique. J Pharm Biomed Anal. 143:43-47. "The results indicated that mitragynine (a kratom derivative) could be a suitable molecule to develop into an opioid replacement drug based on its ideal pharmacokinetic properties, namely, small molecular size, lipophilic in nature and with excellent blood-brain barrier (BBB) permeability."

Kool MB, van Middendorp H, Boeije HR et al. 2009.  Understanding the lack of understanding: invalidation from the perspective of the patient with fibromyalgia. Arthritis Rheum. 61(12):1650-1656.  “Invalidation as perceived by patients with fibromyalgia includes active negative social responses (denying, lecturing, and overprotecting) as well as a lack of positive social responses (supporting and acknowledging) with respect to the patient and the condition of the patient.”  One of the key perpetuating factors of FM is the lack of support of spouse, other family members, co-workers or classmates and friends.  This can come in the form of patronizing, dismissing, and other types of abuse, and more research is needed on how this negative attitude affects people with invisible illnesses.  

Kool MB, Van Middendorp H, Lumley M et al. 2012. Social Support and Invalidation by Others Contribute Uniquely to the Understanding of Physical and Mental Health of Patients with Rheumatic Diseases. J Health Psychol. [Feb 23 Epub ahead of print]. "This study examined whether social support and invalidation (lack of understanding and discounting by others) are differently associated with physical and mental health. Participants were 1455 patients with fibromyalgia, rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, or another rheumatic disease....Social support correlated negatively with discounting responses of others (moderately) and lack of understanding (strongly). Both invalidation and social support were additively associated with patients' mental health, but only discounting was significantly associated with patients' physical health."

Kool MD, Geenen R. 2012. Loneliness in patients with rheumatic diseases: the significance of invalidation and lack of social support. J Psychol. 146(1-2):229-241. "Patients with fibromyalgia experienced significantly more loneliness than patients with ankylosing spondylitis and patients with rheumatoid arthritis. Besides being younger, having lower education, and not working, in multiple regression analyses both lack of social support and invalidation were independently correlated with loneliness. This suggests that to decrease loneliness, therapeutic attention should be given to both increasing social support as well as decreasing invalidation in patients with rheumatic diseases, especially in patients with fibromyalgia."

Kopf A, Janson W, Stein C. 2003.  [Opioid therapy in chronic non-malignant pain] [German]  Anaesthesist. 52(2):103-114.  Therapeutic recommendations from the DGSS consensus conference include a validated indication for the use of opioids for chronic nonmalignant pain.

Koppenhaver S, Embry R, Ciccarello J et al. 2016. Effects of dry needling to the symptomatic versus control shoulder in patients with unilateral subacromial pain syndrome. Man Ther. 26:62-69. "Initial reports suggest that treating myofascial trigger points in the infraspinatus with dry needling may be effective in treating patients with shoulder pain…. This study found changes in shoulder ROM and pain sensitivity, but not in muscle function, after dry needling to the infraspinatus muscle in participants with unilateral subacromial pain syndrome. These changes generally occurred 3-4 days after dry needling and only in the symptomatic shoulders."

Koppert W. 2005.  [Opioid-induced analgesia and hyperalgesia]  Schmerz [Aug 12 Epub ahead of print] [German]  “Successful strategies that may decrease or prevent opioid-induced hyperalgesia include the concomitant administration of drugs such as NMDA antagonists, alpha(2)-agonists, or nonsteroidal anti-inflammatory drugs (NSAID), opioid rotation, or combinations of opioids with different receptor selectivity.”

Koppert, W., P. W. Reeh and H. O. Handwerker. 1993. Conditioning of history mind by bradykinen alters responses of wrapped nociceptors and human itch sensation. Neurosci Lett 152(1-2):117-20.

Korakakis V, Giakas G. 2013. Spinal repositioning deficit. The effect of prolonged flexed posture. Br J Sports Med. 47(10):e3. "Flexed sitting posture is commonly adopted in daily sitting activities and when sustained has been proposed to affect biological properties of spinal tissues and act detrimentally on proprioception. The objective of this study by using an optoelectronic motion analysis system was to assess sitting posture regarding the head, spine and pelvis, in healthy individuals; the time effect of flexed posture (FSP) on proprioception and the impact of an MDT (Mechanical Diagnosis and Therapy) procedure on proprioceptive deficit. …Postural repositioning error showed significant differences for LU (lumbar) and HE (head) angles. The findings suggest that healthy individuals habitually sit in more flexed posture than SPOP (optimal sitting posture) and IOSP (instructed sitting posture). Postural education can be actualized in a reliable way and subjects can adopt an educated posture. Furthermore FSP (habitual sitting posture) challenged postural proprioception, but SOP increased proprioceptive accuracy." [Immobility in this flexed posture could activate myofascial trigger points, causing the effects noted here, but they were not mentioned. DJS]

Korkmaz S, Karadag MA, Hamamcioglu K et al. 2015. Electrophysiological identification of central sensitization in patients with chronic prostatitis. Urol J. 12(4):2280-2284. "These results support the presence of central sensitization because of exaggerated transmission of pain sensation to the somatosensory cortex. Therefore, normalization of transmission might be an important step in treatment of pain in patients with CP/CPPS. This study can be counted as an important guiding on pathogenesis and treatment of disease." Free Article

Kornick CA, Santiago-Palma J, Moryl N et al. 2003.  Benefit-risk assessment of transdermal fentanyl for the treatment of chronic pain.  Drug Saf 26(13):951-973.  “Transdermal fentanyl is effective and well tolerated for the treatment of chronic pain caused by malignancy and non-malignant conditions when administered according to the manufacturer’s recommendations.  Compared with oral opioids, advantages of transdermal fentanyl include a lower incidence and impact of adverse effects (constipation, nausea and vomiting, and daytime drowsiness), higher degree of patient satisfaction, improved quality of life, improved convenience and compliance resulting from administration every 72 hours, and decreased use of rescue medication.”

Kosek E, Martinsen S, Gerdle B et al. 2016. The translocator protein gene is associated with symptom severity and cerebral pain processing in fibromyalgia. Brain Behav Immun. [Jul 20 Epub ahead of print.] When glial cell activation occurs in chronic pain (this occurs in FM), the translocator protein becomes more available. That protein is the rate-limiting step for the process of synthesizing neurosteroids, and affects transmission across the nerve synapses. This research investigated a genetic variation that affects this protein. The FM patients that had this genetic variation had higher pain severity. The authors wrote: "To our knowledge this is the first evidence of functional genetic polymorphisms affecting pain severity in FM and our findings are in line with proposed glia-related mechanisms. Furthermore, the functional magnetic resonance findings indicated an effect of translocator protein on the affective-motivational components of pain perception."

Kosek E, Rosen A, Carville S et al. 2017. Lower placebo responses after long-term exposure to fibromyalgia pain. J Pain. [Mar 6 Epub ahead of print.] "Knowledge about placebo mechanisms in patients with chronic pain is scarce. Fibromyalgia syndrome (FM) is associated with dysfunctions of central pain inhibition, and since placebo analgesia entails activation of endogenous pain inhibition, we hypothesized that long-term exposure to FM pain would negatively affect placebo responses…. Here, we demonstrate that FM duration influences endogenous pain regulation, as pain levels and placebo-induced analgesia were negatively affected. Our results point to the importance of early FM interventions, as endogenous pain regulation may still be harnessed at that early time. Also, placebo-controlled trials should take FM duration into consideration when interpreting results." Free Article

Koseoglu HI, Inanır A, Kanbay A et al. 2017. Is there a link between obstructive sleep apnea syndrome and fibromyalgia syndrome? Turk Thorac J. 18(2):40-46. "OSAS was detected in 50% of patients with FMS. The most prominent clinical findings were morning fatigue and sleep disorder, which were similar in three groups. In polysomnography (PSG) evaluation, patients with FMS had mild (33%), moderate (25%), and severe (42%) OSAS. In correlation analyses, negative correlations were observed between fibromyalgia impact questionnaire (FIQ) and mean oxygen saturation, visual analogue scale (VAS), and minimum oxygen saturation, whereas a positive correlation was found between FIQ and desaturation times in patients with FMS. CONCLUSION: Detection of OSAS in 50% of the patients with FMS, and similar rates of complaints of sleep disorder and morning fatigue of OSAS and FMS cases are important results. Detection of correlation between the severity of hypoxemia and FIQ and VAS scores are significant because it signifies the contribution of increased tissue hypoxemia to the deterioration of clinical status. Diagnosis and treatment of OSAS associated with FMS are important because of their favorable contributions to the improvement of the clinical picture of FMS."

Kosmidis ML, Koutsogeorgopoulou L, Alexopoulos H et al. 2014. Reduction of Intraepidermal Nerve Fiber Density (IENFD) in the skin biopsies of patients with fibromyalgia: A controlled study. J Neurol Sci. Sep 28. [Epub ahead of print] "This is one of the largest series of FM patients demonstrating a significant reduction of IENFD (Intraepidermal Nerve Fiber Density) in their skin biopsies. The findings indicate that in a subset of FM patients, the pain syndrome is, at least partially, of neuropathic origin. Skin biopsy may prove a useful tool and a potential biomarker in future studies of FM patients."

Kostopoulos D. 2007.  Reduction of spontaneous electrical activity and pain perception of trigger points in the upper trapezius muscle through trigger point compression and passive stretching.  J Musculoskel Pain 15 (Supp 13):27 item 44.  [Myopain 2007 Poster]  “Although each technique significantly reduced pain perception and SEA (spontaneous electrical activity) the combination of Ic (ischemic compression) and PS (passive stretching) was superior, apparently because of the complementary nature of the therapeutic interventions.”

Kotagal S, Nichol CD, Grigg-Damberger MM et al. 2012. Non-respiratory indications for polysomnography and related procedures in children: An evidence-based review. Sleep. 35(11): 1451–1466. "This evidence-based review provides a systematic and comprehensive review of the literature regarding the utility of polysomnography for the evaluation of non-respiratory sleep disorders in children including hypersomnias, parasomnias, sleep-related movement disorders, and sleep in other special populations…. The main results include (1) polysomnography combined with the multiple sleep latency test is useful for evaluating disorders of excessive somnolence to objectively quantify sleepiness. The results have to be interpreted with consideration of the pubertal stage and regularity of the sleep patterns of the child; (2) polysomnography is indicated in children with parasomnias or sleep related movement disorders who have a high likelihood of having obstructive sleep apnea (OSA); (3) polysomnography is not routinely indicated in children with enuresis unless there is a high likelihood of OSA; (4) polysomnography can be helpful in evaluating children with restless legs syndrome (RLS) and when periodic limb movement disorder (PLMD) is suspected…. These findings suggest that, in children with non-respiratory sleep disorders, polysomnography should be a part of a comprehensive sleep evaluation in selected circumstances to determine the nature of the events in more detail or when the suspicion of OSA is relatively high."

Kotarinos R. 2012. Myofascial pelvic pain. Curr Pain Headache Rep. 16(5):433-438. "Myofascial pelvic pain is fraught with many unknowns. Is it the organs of the pelvis, is it the muscles of the pelvis, or is the origin of the pelvic pain from an extrapelvic muscle? Is there a single source or multiple? In this state of confusion what is the best way to manage the many symptoms that can be associated with myofascial pelvic pain. This article reviews current studies that attempt to answer some of these questions. More questions seem to develop as each study presents its findings."

Kotarinos RK. 2003.  Pelvic floor physical therapy in urogynecologic disorders.  Curr Womens Health Rep. 3(4):334-339.

Kotter I, Neuscheler D, Gunaydin I et al. 2007.  Is there a predisposition for the development of autoimmune diseases in patients with fibromyalgia?  Retrospective analysis with long term follow-up.  Rheumatol Int. [Jul 20 Epub ahead of print].  “The risk of CTD (connective tissue disease) is not increased in FM.  The detection of ANA (antinuclear antibodies) does not predict the development of CTD.”

Kovacevic-Ristanovic, R., R. D. Cartwright and S. Lloyd.  1991.  Nonpharmacologic treatment of period leg movements in sleep.  Arch Phys Med Rehabil 72(6):385-9.

Kovacic K, Chelimsky TC, Sood MR. 2014. Joint Hypermobility: A Common Association with Complex Functional Gastrointestinal Disorders. J Pediatr. [Aug 20 Epub ahead of print.] Comorbid conditions were common, including sleep disturbances (77%), chronic fatigue (93%), dizziness (94%), migraines (94%), chronic nausea (93%), and fibromyalgia (24%)….JH (joint hypermobility) and other comorbid symptoms, including fibromyalgia, occur commonly in children and young adults with complex FGIDs (functional gastrointestinal disorders). POTS is prevalent in FGIDs but is not associated with hypermobility. We recommend screening patients with complex FGIDs for JH, fibromyalgia, and comorbid symptoms such as sleep disturbances, migraines, and autonomic dysfunction.

Kovacs, F. M., V. Abraira, F. Pozo, D. G. Kleinbaum, J. Beltran, I. Mateo, C. Perez de Ayala, A. Pena, A. Zea, M. Gonzalez-Lanza and L. Morillas.  1997.  Local and remote sustained trigger point therapy for exacerbations of chronic low back pain.  A randomized, double-blind, controlled, multicenter trial.  Spine 22(7):786-797.

Krakow B, Melendrez D, Warner TD et al. 2002. To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors. Sleep Breath. 6(4):189-202. "Post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia."

Kratz AL, Schilling S, Goesling J et al. 2015. Development and Initial Validation of a Brief Self-Report Measure of Cognitive Dysfunction in Fibromyalgia. J Pain. [Mar 4 Epub ahead of print.] "This paper presents the Multidimensional Inventory of Subjective Cognitive Impairment (MISCI), a 10-item measure of cognitive dysfunction in fibromyalgia, developed through classical test theory and item response theory. This brief but comprehensive measure shows evidence of excellent construct validity through large correlations with a lengthy legacy measure of cognitive functioning." [This important diagnostic list, coupled with the understanding brought to light by recent research that the cognitive impairments of FM do not lead to Alzheimer's, may bring peace of mind to many FM patients. DJS]

Kravitz HM, Katz RS. 2015. Fibrofog and fibromyalgia: a narrative review and implications for clinical practice. Rheumatol Int. [Jan 13 Epub ahead of print.] "Patients with fibromyalgia often report forgetfulness as well as declines in cognitive function, memory, and mental alertness-symptoms that have been termed 'fibrofog' in popular and electronic media as well as in professional literature. 'Fibrofog' is the subjectively experienced cognitive dysfunction associated with fibromyalgia and is a clinically important yet comparatively less well-studied aspect of the disorder; it includes loss of mental clarity (mental fogginess) as well as attention and memory impairment. Although until recently cognitive symptoms have been largely ignored, these symptoms can be more disturbing than the widespread pain and can change these patients' lives, sometimes dramatically so. Whereas widespread musculoskeletal pain, tenderness, and fatigue may be the hallmark symptoms of fibromyalgia, patients rank cognitive dysfunction highly in terms of disease impact. This review addresses (1) the prevalence of self-reported cognitive disturbances in fibromyalgia, (2) the clinical presentation of fibrofog, (3) neuropsychological test performance, with particular attention to discrepancies between self-report and test results, (3) clinical correlates of impaired cognitive function in fibromyalgia, (4) neurobiology relevant to cognitive disturbances in fibromyalgia, and (5) clinical management of fibrofog. Although the pathophysiology of fibromyalgia remains an enigma, evidence suggests that it may be a brain disorder, with cognitive deficits ('fibrofog') reflecting disturbed centrally mediated processes."

Kreczy, A., M. Kofler and A. Gschwendtner. 1999.  Underestimated health hazard: proposal for an ergonomic microscope workstation.  Lancet 354:1701-1702.

Krishman SK, Benzon HT, Siddiqui T et al. 2000.  Pain on intramuscular injection of bupivacaine, ropivacaine, with and without dexamethasone.  Reg Anesth Pain Med 25(6):615-619.  “The pain on intramuscular injection of bupivacaine is significantly more intense than with ropivacaine.”  Yet another study documenting that Marcaine is not acceptable for TrP injections.

Kristensen KD1, Stoustrup P2, Küseler A3, Pedersen TK3, Twilt M4, Herlin T4.1 Section of Orthodontics, Aarhus University, Vennelyst Boulevard 9, Aarhus C DK-8000, Denmark; Specialist Oral Health Center for Western Norway, Stavanger, Rogaland, Norway. Electronic address: kdki@odont.au.dk. To assess the level of evidence for subjective and objective parameters in clinical orofacial examination and determine if predictors for temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) patients exist in the current literature. RESULTS: The electronic database search identified 345 unique citations. After application of our strict, predefined inclusion and exclusion criteria, 21 articles were included and data extracted. The study heterogeneity did not allow for meta-analyses. No singular outcome measure can be suggested as a predictor of TMJ involvement in JIA, as sensitivity and/or specificity is too low compared to contrast-enhanced magnetic resonance imaging. CONCLUSION: The current low level of evidence and study heterogeneity do not allow us to conclude on singular clinical outcome measures. To increase study comparability, we call for a standardized terminology and evidence-based guidelines for clinical orofacial examination parameters in JIA patients.

Kroenke K, Cheville A. 2017. Management of chronic pain in the aftermath of the opioid backlash. JAMA. [May 11 Epub ahead of print.] These authors warn of the dangers of the current fear-based "movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments". Chronic pain patients who are on successful opioid treatment "should not be unilaterally compelled to wean off opioids." They warn of the dangers of many medications that are now being used as opioid-alternatives, such as NSAIDS, gabapentin and pregabalin. "Given the small analgesic effect on average of most pain drugs, the few classes of analgesic options, and the frequent need for combination therapy, eliminating any class of analgesics from the current menu is undesirable." [Dr. Kronke is a professor at the University of Indiana School of Medicine and a research scientist. Dr. Cheville is chair of research at the Mayo Clinic Dept. of Physical Medicine and Rehabilitation. It is to be hoped that pain management people and primary care providers read this important article and take it to heart. DJS]

Kross E, Berman MG, Mischel W et al. 2011. Social rejection shares somatosensory representations with physical pain. Proc Natl Acad Sci USA [Mar 28 Epub ahead of print]. "These results give new meaning to the idea that rejection 'hurts'. They demonstrate that rejection and physical pain are similar not only in that they are both distressing - they share a common somatosensory representation as well."[This may be how emotional pain contributes to central pain states such as fibromyalgia. DJS]

Krylov VV. 2017. Biological effects related to geomagnetic activity and possible mechanisms. Bioelectromagnetics. 38:497-510. "This review presents contemporary data on the biological effects of geomagnetic activity. Correlations between geomagnetic indices and biological parameters and experimental studies that used simulated geomagnetic storms to detect possible responses of organisms to these events in nature are discussed. Possible mechanisms by which geomagnetic activity influences organisms are also considered. Special attention is paid to the idea that geomagnetic activity is perceived by organisms as a disruption of diurnal geomagnetic variation. This variation, in turn, is viewed by way of a secondary zeitgeber for biological circadian rhythms. Additionally, we discuss the utility of cryptochrome as a biological detector of geomagnetic storms. The possible involvement of melatonin and protein coding by the CG8198 gene in the biological effects of geomagnetic activity are discussed. Perspectives for studying mechanisms by which geomagnetic storms affect organisms are suggested." (Russian) [There may be many variables affecting geomagnetic sensitivity, including things outside the electromagnetic spectrum. There is a lot that we don't know. DJS]

Kuan LC, Li YT, Chen FM et al. 2006.  Efficacy of treating abdominal wall pain by local injection.  Taiwan J Obstet Gynecol. 45(3):239-243.  “Local injection for selective abdominal wall pain patients produces significant pain relief.  The diagnosis of abdominal wall pain is an important component in avoiding unnecessary operations in patients with abdominal pain.”

Kuan TS, Chen JT, Chen SM, Chien CH, Hong CZ. 2002. Effect of botulinum toxin on endplate noise in myofascial trigger spots of rabbit skeletal muscle.  Am J Phys Med Rehabil 81(7):512-20.  This study confirms the association of excess acetylcholine in the motor endplates as part of the pathogenesis of myofascial trigger points.

Kuan TS, Hong CZ, Chen JT et al. 2007.  The spinal cord connections of the myofascial trigger spots.  Eur J Pain 11(6):624-634.  “Background: Recent electrophysiological studies revealed that endplate noise (EPN) could be specifically recorded from a myofascial trigger point (MTrP) region.  EPN has been considered as the focal graded potentials due to excessive acetycholine release in neuromuscular junction.”  “The spinal cord connections of an MTrS (myofascial trigger spot) are basically similar to that for a normal tissue region.  The motor neurons related to MTrS tended to be smaller in their diameters.  The findings in this study further supported the previously proposed hypotheses for the pathogenesis of an MTrP.”

Kuan TS, Hong CZ, Chen SM et al. 2012. Myofascial pain syndrome: correlation between the irritability of trigger points and the prevalence of local twitch responses during trigger point injection. J Musculoskel Pain. 20(4):250-256. The local twitch response appears to be a reflex contraction of muscle fiber within the TrP taut band. The LTR occurs when the nociceptors in the taut band are stimulated, such as during TrP injection or dry needling "This study supports the hypothesis that in MPS there are multiple sensitized loci nociceptors in TrP regions and that the Local Twitch Response is related to the irritability of the TrP." This study found a high correlation of LTR during injection and intensity of pain or pressure pain threshold before injection. We don't yet know why it is so critical for pain relief to elicit an LTR during injection. The prevalence of LTR seems to be highly associated with the LTR. The amount of pain relief was in proportion to the LTR only when the mean intensity of pain was very high before injection.

Kuan TS, Hsieh YL, Chen SM et al. 2007.  The myofascial trigger point region: correlation between the degree of irritability and the prevalence of endplate noise.  Am J Phys Med Rehabil. 86(3):183-189.  “The irritability of an MTrP is highly correlated with the prevalence of EPN in the MTrP region of the upper trapezius muscle.  The assessment of EPN prevalence in an MTrP region may be applied to evaluate the irritability of that MTrP.”

Kuch, K., B. J. Cox and R. J. Evans. 1996. Posttraumatic stress disorder and motor vehicle accidents: a multidisciplinary overview. Can J Psychiatry 41(7):429-434.

Kuch, K., B. Cox, R. J. Evans,  P. C. Watson and C. Bubela. 1993. To what extent do anxiety and depression interact with chronic pain? Can J Psychiatry 38(1):38(1):36-38.

Kuchinad A, Schweinhardt P, Seminowicz DA et al. 2007.  Accelerated brain gray matter loss in fibromyalgia patients: premature aging of the brain?  J Neurosci. 27(15):4004-4007.  “…fibromyalgia patients had significantly less total gray matter volume and showed a 3.3 times greater age-associated decrease in gray matter than healthy controls.  The longer the individuals had had fibromyalgia, the greater the gray matter loss, with each year of fibromyalgia being equivalent to 9.5 times the loss in normal aging.  In addition, fibromyalgia patients demonstrated significantly less gray matter density than healthy controls in several brain regions, including the cingulate, insular and medical frontal cortices, and parahippocampal gyri.”   “...fibromyalgia appears to be associated with an acceleration of age-related changes in the very substance of the brain.  Moreover, the regions in which we demonstrate objective changes may be functionally linked to core features of the disorder including affective disturbances and chronic widespread pain.”

Kucuksen S, Genc E, Yilmaz H et al. 2013. The prevalence of fibromyalgia and its relation with headache characteristics in episodic migraine. Clin Rheumatol. [Feb 27 Epub ahead of print]. "This study indicates that the assessment and management of coexisting FM should be taken into account in the assessment and management of migraine, particularly when headache is severe or patients suffer from widespread musculoskeletal pain."

Kuhajda, M. C., B. E. Thorn and M. R. Klinger.  1998.  The effect of pain on memory for affective words.  Ann Behav Med 20(1):31-5.

Kumar S, Ferrari R, Narayan Y. 2004.  Cervical muscle response to posterolateral impacts — effect of head rotation.  Clin Biomech 19(9):899-905.  “Head rotation in a right posterolateral impact modifies the cervical response mainly by generating an asymmetry in the paired sternocleidomastoid electromyograms.  This may asymmetrically affect the risk of injury to the sternocleidomastoids “  

Kumar S, Ferrari R, Narayan Y. 2004.  Electromyographic and kinematic exploration of whiplash-type rear impacts: effect of left offset impact.  Spine J. 4(6):656-665.  “When a rear impact is offset to the subject’s left, it results in not only increased electromyographic generation in both sternocleidomastoids, but the splenius capitis contralateral to the direction of impact offset also bears part of the force of the neck perturbation.  Expecting or being aware of imminent impact also plays a role in reducing muscle responses in low-velocity offset rear impacts.”  [It is an interesting reflection that while some researchers are working to understand the mechanisms of whiplash and thus benefiting patients and care providers, and perhaps preventing further injury, there are  doctors  (primarily under the pay and/or influence of insurance companies) who still refuse to believe whiplash exists. DJS]

Kumar S, Narayan Y, Amell T. 2002. An electromyographic study of low-velocity rear-end impacts. Spine 27(10):1044-1055. “Muscle responses were greater with higher levels of acceleration. Because the muscular component of the head-neck complex plays a central role in the abatement of higher acceleration levels, it may be a primary site of injury in the whiplash phenomenon.”

Kumbhare D, Ahmed S, Watter S. 2018. A narrative review on the difficulties associated with fibromyalgia diagnosis. Ther Adv Musculoskelet Dis. 10(1):13-26. "Fibromyalgia presents a clinical enigma as its pathophysiology is not well understood and its symptoms are nonspecific and overlap with many disorders, making its diagnosis a challenge for clinicians and researchers. Efforts have been made to develop a set of diagnostic criteria for this disorder. However, these criteria rely heavily on expert clinician opinion and produce a large heterogeneity within the diagnosed population. With no present specific technique reflecting the underlying pathophysiology of fibromyalgia, a definitive diagnosis of fibromyalgia remains elusive. This review discusses some problems and challenges associated with fibromyalgia diagnosis and presents some novel findings on the pathophysiological nature of fibromyalgia." Free Article

Kumbhare D, Shaw S, Grosman-Rimon L et al. 2017. Quantitative ultrasound assessment of myofascial pain syndrome affecting the trapezius: A reliability study. J Ultrasound Med. [Jul 3 Epub ahead of print] "Myofascial pain syndrome is one of the most common causes of chronic pain and is highlighted by the presence of myofascial trigger points. The current practice of diagnosing myofascial pain syndrome among clinicians involves manual detection of myofascial trigger points, which can be inconsistent. However, the detection process can be strengthened with the assistance of ultrasound (US). Therefore, this study aimed to characterize the upper trapezius by using quantitative techniques in healthy asymptomatic individuals with neck pain….Study participants were recruited on the basis of the inclusion and exclusion criteria established, and US images of the trapezius, along the axial and longitudinal orientations, were obtained. Each set was obtained by 2 investigators: experienced and inexperienced personnel….This study demonstrated that quantitative analysis of the echo intensity of US images can provide important information. However, further research is necessary to explore the relationships among sex, age, blob area, count, body mass index, regional anatomy, and extent of training or exercise of the particular muscle."

Kundermann B, Krieg JC, Schreiber W et al. 2004.  The effect of sleep deprivation on pain.  Pain Res Manag. 9(1):25-32.  “Chronic pain syndromes are associated with alterations in sleep continuity and sleep architecture.  One perspective of this relationship, which has not received much attention to date, is that disturbances of sleep affect pain.  Sleep deprivation produces hyperalgesic changes.  Sleep deprivation can counteract analgesic effects of pharmacological treatments involving opioidergic and serotoninergic mechanisms of action.”

Kung YY, Chen FP, Chaung HL et al. 2001.  Evaluation of acupuncture effect to chronic myofascial pain syndrome in the cervical and upper back regions by the concept of Meridians.  Acupunct Electrother Res. 26(3):195-202.  “Acupuncture is a somewhat effective method for pain relief of patients with chronic MPS in the cervical and upper back regions.  The effect of acupuncture with the concept of meridians on MPS is insidious and the duration of the relief is not long enough.”

Kuo TL1, Ng LG, Chapple CR. 2015. Pelvic floor spasm as a cause of voiding dysfunction. Curr Opin Urol. 25(4):311-316. "Pelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction…. To distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms."

Kurland JE, Coyle WJ, Winkler A et al. 2006.  Prevalence of irritable bowel syndrome and depression in fibromyalgia.  Dig Dis Sci. 51(3):454-460.  “The prevalence of IBS and depressive symptoms was higher in FM patients compared to the control population.”

Kurosinski P, Gotz J. 2002.  Glial cells under physiologic and pathologic conditions.  Arch Nerol 59(10):1524-8. Glial cell loss may contribute to cognitive deficits such as memory impairment.

Kurtzer I, Meriggi J, Parikh N et al. 2016. Long-latency reflexes of elbow and shoulder muscles suggest reciprocal excitation of flexors, reciprocal excitation of extensors, and reciprocal inhibition between flexors and extensors. J Neurophysiol. 115(4):2176-2190. "Postural corrections of the upper limb are required in tasks ranging from handling an umbrella in the changing wind to securing a wriggling baby. One complication in this process is the mechanical interaction between the different segments of the arm where torque applied at one joint induces motion at multiple joints. Previous studies have shown the long-latency reflexes of shoulder muscles (50-100 ms after a limb perturbation) account for these mechanical interactions by integrating information about motion of both the shoulder and elbow. It is less clear whether long-latency reflexes of elbow muscles exhibit a similar capability and what is the relation between the responses of shoulder and elbow muscles. The present study utilized joint-based loads tailored to the subjects' arm dynamics to induce well-controlled displacements of their shoulder and elbow. Our results demonstrate that the long-latency reflexes of shoulder and elbow muscles integrate motion from both joints: the shoulder and elbow flexors respond to extension at both joints, whereas the shoulder and elbow extensors respond to flexion at both joints. This general pattern accounts for the inherent flexion-extension coupling of the two joints arising from the arm's intersegmental dynamics and is consistent with spindle-based reciprocal excitation of shoulder and elbow flexors, reciprocal excitation of shoulder and elbow extensors, and across-joint inhibition between the flexors and extensors." [One of the most common causes of muscle weakness is an alteration of reciprocal inhibition due to trigger points. If a muscle is weak due to reciprocal inhibition, the solution is not to overwork it more by strengthening exercises. That will make the muscle worse. Find the muscle that is inhibiting the weak muscle and treat that. Once muscles are properly treated for trigger points and other causes of dysfunction, strength will return. DJS]

Kusano M, Kouzu T, Kawano T et al. 2008. Nationwide epidemiological study on gastroesophageal reflux disease and sleep disorders in the Japanese population. J Gastroenterol. 43(11):833-841. "In Japanese people, patients with heartburn had a significantly higher prevalence of sleep disorders than those without heartburn." [Another good study verifying this link. Sleep studies, which should be part of all FM workups, should include testing for GERD. GERD may often by "silent," lacking usual symptoms. DJS]

Kushida CA, Giacomini A, Lee MK et al. 2002. Technical protocol for the use of esophageal manometry in the diagnosis of sleep-related breathing disorders. Sleep Med. 3(2):163-173. "Esophageal manometry is an invaluable tool for the sleep specialist in the diagnosis of sleep-related breathing disorders, especially for detecting cases of upper airway resistance syndrome and for distinguishing subtle central apneas from obstructive events."

Kushida CA, Sherrill CM, Hong SC et al. 2001. Cervical positioning for reduction of sleep-disordered breathing in mild-to-moderate OSAS. Sleep Breath. 5(2):71-78. Positioning of the head and neck with proper cervical support may reduce sleep impairment in some patients with mild to moderate obstructive sleep apnea.

Kutch JJ1, Ichesco E, Hampson JP et al. 2017. Brain signature and functional impact of centralized pain: a Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Network Study. Pain. [Jun 30 Epub ahead of print] "Here, we investigated whether centralization is manifested at the level of the brain using data from 1079 participants in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network (MAPP) study. Participants with a clinical diagnosis of urological chronic pelvic pain syndrome (UCPPS) were compared to pain-free controls and fibromyalgia patients, the prototypical centralized pain disorder…. Widespread UCPPS patients displayed increased brain gray matter volume and functional connectivity involving sensorimotor and insular cortices…. These changes translated across disease diagnoses as identical outcomes were present in fibromyalgia patients but not pain-free controls. Widespread pain was also associated with reduced physical and mental function independent of pain severity. Brain pathology in centralized pain patients is related to pain distribution throughout the body. These patients may benefit from interventions targeting the central nervous system."

Kwon J, Kim HS, Chang WH et al. 2017. Characteristics of myofascial pain syndrome of the infraspinatus muscle. Ann Rehabil Med. 41(4):573-581. The most common chief complaint area of MTrPs (myofascial trigger points) in the infraspinatus muscle was the scapular area. The most common pattern of referred pain was the anterolateral aspect of the arm (above the elbow). Active MTrPs were multiple rather than single in the infraspinatus muscle. MTrPs were frequently in the center of the muscle. Trigger-point injection of the infraspinatus muscle significantly decreased the pain intensity. Mean VAS score decreased significantly after the first injection compared to the baseline….. Free Article

Kyle SD, Miller CB, Rogers Z, Siriwardena AN et al. 2014. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder. SLEEP 37(2):229-237. "For the first time we show that acute sleep restriction therapy is associated with reduced objective total sleep time, increased daytime sleepiness, and objective performance impairment. Our data have important implications for implementation guidelines around the safe and effective delivery of cognitive behavioral therapy for insomnia."


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