December 2013 References  Devin J. Starlanyl   for

Adelowo A, Hacker MR, Shapiro A et al. 2013. Botulinum toxin type A (BOTOX) for refractory myofascial pelvic pain. Female Pelvic Med Reconstr Surg. 19(5):288-292. “Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few self-limiting adverse effects”.

Bismil Q, Bismil M. 2013. Myofascial-entheseal dysfunction in chronic whiplash injury: an observational study.  JRSM Short Rep. 3(8):57.  “1025 consecutive patients with chronic whiplash with neck pain and reduced cervical spine range of motion and trapezius trigger points were seen in this large orthopedic practice seen during a 4-year period.  They all had trapezius-associated enthesopathy. This observational paper proposes a change of the definition of chronic whiplash associated disorder to “a painful syndrome following acceleration-deceleration injury with neck stiffness; and myofascial-entheal dysfunction”.  [Dysfunction of the enthesis, or attachment area, can be a critical part of any injury involving the joint area. DJS]

Blazquez A, Ruiz E, Aliste L et al. 2013. The impact of fatigue and fibromyalgia on sexual dysfunction in women with chronic fatigue syndrome. J Sex Marital Ther. [Nov 25 Epub ahead of print]. “Sexual dysfunction in patients with chronic fatigue syndrome (CFS) is attracting growing interest but has been analyzed by few studies to date. For this reason we evaluate sexual dysfunction in women with CFS (GRISS) and explore correlations with fatigue and other symptoms. Sexual dysfunction was greater in CFS patients… with a higher number of cognitive, neurological, and neurovegetative symptoms, concomitant fibromyalgia, Sjogren's syndrome, or myofascial pain syndrome, and more intense fatigue….”

Block C, Cianfrini L. 2013. Neuropsychological and neuroanatomical sequelae of chronic non-malignant pain and opioid analgesia. NeuroRehabilitation. 33(2):343-366. “To date, evidence from opioid studies suggests only mild deficits in specific cognitive domains (e.g., memory, attention/concentration) and only under specific conditions (e.g., dose escalations). Additionally, neuroimaging and neuropsychological evidence suggests that pain itself results in cognitive sequelae. Methodological improvements in future research will allow for better delineation of the contributing effects of pain and opioids, with an overall goal of improving evidence-based clinical treatment recommendations.”

Burston JJ, Sagar DR, Shao P et al. 2013. Cannabinoid CB2 receptors regulate central sensitization and pain responses associated with osteoarthritis of the knee joint. PLoS One. 8(11):e80440. “Osteoarthritis (OA) of the joint is a prevalent disease accompanied by chronic, debilitating pain. Recent clinical evidence has demonstrated that central sensitization contributes to OA pain. An improved understanding of how OA joint pathology impacts upon the central processing of pain is crucial for the identification of novel analgesic targets/new therapeutic strategies. Inhibitory cannabinoid 2 (CB2) receptors attenuate peripheral immune cell function and modulate central neuro-immune responses in models of neurodegeneration. Systemic administration of the CB2 receptor agonist JWH133 attenuated OA-induced pain behavior, and the changes in circulating pro- and anti-inflammatory cytokines exhibited in this model. Electrophysiological studies revealed that spinal administration of JWH133 inhibited noxious-evoked responses of spinal neurones in the model of OA pain, but not in control rats, indicating a novel spinal role of this target. We further demonstrate dynamic changes in spinal CB2 receptor mRNA and protein expression in an OA pain model. The expression of CB2 receptor protein by both neurones and microglia in the spinal cord was significantly increased in the model of OA…. These data provide new clinically relevant evidence that joint damage and spinal CB2 receptor expression are correlated combined with converging pre-clinical evidence that activation of CB2 receptors inhibits central sensitization and its contribution to the manifestation of chronic OA pain. These findings suggest that targeting CB2 receptors may have therapeutic potential for treating OA pain.”

Castro-Sanchez AM, Aguilar-Ferrandiz ME, Mataran-Penarrocha GA et al. 2013. Short-term effects of a manual therapy protocol on pain, physical function, quality of sleep, depressive symptoms and pressure sensitivity in women and men with fibromyalgia syndrome: A randomized controlled trial. Clin J Pain. [Nov 25 Epub ahead of print]. “Manual therapy protocol was effective for improving pain intensity, widespread pressure pain sensitivity, impact of FMS symptoms, sleep quality and depressive symptoms. In addition, sex differences were observed in response to treatment: women and men get similar improvements in quality of sleep and tender point count, whereas women showed a greater reduction in pain and impact of FMS symptoms than men, but men reported higher decreases in depressive symptoms and pressure hypersensitivity than women.”

Chung M, Wang C. 2013. Can alcohol consumption be an alternative treatment for fibromyalgia? Arthritis Res Ther. 15(6):126. “Treatment of chronic pain conditions such as fibromyalgia is challenging due to limitations of drug therapies. An initial exploration into the relationships between self-reported alcohol consumption, symptom severity, and quality of life for individuals with fibromyalgia sheds new light on plausible hypotheses and potential mechanisms of action for future research. Evidence suggests that alcohol consumption may improve social and psychological factors because of activity in the ascending and descending pain pathways in modulating gamma-aminobutyric acid neurotransmission. Further methodologically rigorous studies in this field to improve well-being of individuals with fibromyalgia are warranted.” (From Tufts University School of Medicine)

Clewley D, Flynn TW, Koppenhaver S. 2013. Trigger point dry needling as an adjunct treatment for a patient with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther. [Nov 21 Epub ahead of print].  “Prognosis for adhesive capsulitis has been described as self-limiting and can persist for 1-3 years. Conservative treatment including physical therapy is commonly advised…. The patient was a 54 year old female with primary symptoms of shoulder pain and loss of motion consistent with adhesive capsulitis. Manual physical therapy intervention initially consisted of joint mobilizations of the shoulder region and thrust manipulation of the cervicothoracic region. Although manual techniques seemed to cause some early functional improvement, continued progression was limited by pain. Subsequent examination identified trigger points in the upper trapezius, levator scapula, deltoid and infraspinatus muscles that were treated with dry needling to decrease pain and allow for higher grades of manual intervention. Outcomes: The patient was treated for a total of 13 visits over a 6 weeks period. After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range of motion and functional outcome measures…exceeded the minimal clinically important difference after 2 treatment sessions. At discharge the patient had achieved significant improvements in shoulder range of motion in all planes and outcome measures were significantly improved….This case report describes the clinical reasoning behind the use of trigger point dry needling in the treatment of a patient with adhesive capsulitis. The rapid improvement seen in this patient following the initiation of dry needling to the upper trapezius, levator scapula, deltoid and infraspinatus muscles suggests that surrounding muscles may be a significant source of pain in this condition.”

Diaz-Piedra C, Catena A, Miro E et al. 2013. The impact of pain on anxiety and depression is mediated by objective and subjective sleep characteristics in fibromyalgia patients. Clin J Pain. [Nov 25 Epub ahead of print]. “Subjective poor sleep quality was found in all patients. Pain correlated with subjective and objective sleep parameters, self-efficacy, anxiety, and, marginally, with depression. The mediated regression analysis suggested that the best models to explain the impact of pain on anxiety and depression included, as mediators, subjective sleep quality, objective sleep efficiency and self-efficacy….objective sleep efficiency being the mediator with the highest influence….These findings show a high prevalence of sleep problems in patients with FMS and suggest that they play a role in the relationship between pain and anxiety and depression. In fact, the impact of chronic pain on the later emotional variables was mediated, not only by self-efficacy, but also by subjective sleep quality and, especially, by objective sleep efficiency.”

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.”

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 that was persistent, lasted longer than 3 months, and had characteristic pain on palpation. Subjects in the "no pain" (NP) group had no spontaneous pain. However, some of these subjects had discomfort upon MTrP palpation (latent MTrP), whereas others in the NP group had no discomfort upon palpation of nodules or had no nodules….A systematic musculoskeletal evaluation of people with MPS reliably distinguishes them from subjects with no pain. The 2 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.”

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.”

Huang QM, Ye G, Zhao ZY. 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.  This paper indicates that blunt trauma followed by intensive exercise, at least in rats, can cause trigger points.

Iglesias-Gonzalez JJ, Munoz-Garcia 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. [Aug 15 Epub ahead of print]. “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.”

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.

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 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 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.”

Lee MC, Wanigasekera V, Tracey I. 2013. Imaging opioid analgesia in the human brain and its potential relevance for understanding opioid use in chronic pain. Neuropharmacology. [Jul 25 Epub ahead of print]. “Opioids play an important role for the management of acute pain and in palliative care. The role of long-term opioid therapy in chronic non-malignant pain remains unclear and is the focus of much clinical research. There are concerns regarding analgesic tolerance, paradoxical pain and issues with dependence that can occur with chronic opioid use in the susceptible patient. In this review, we discuss how far human neuroimaging research has come in providing a mechanistic understanding of pain relief provided by opioids, and suggest avenues for further studies that are relevant to the management of chronic pain with opioids.”

Lillefjell M, Haugan T, Martinussen P et al. 2013. Non-ketogenic, low carbohydrate diet predicts lower affective distress, higher energy levels and decreased fibromyalgia symptoms in middle aged females with fibromyalgia syndrome as compared to the western pattern diet.  J Musculoskel Pain 21(4):311-319.  The non-ketogenic, low-carbohydrate diet improved mood, energy levels and confusional states and other symptoms in patients with fibromyalgia syndrome. [Although the authors mentioned this diet as improvement of “functional” and “affective” symptoms, they may be treating co-existing insulin resistance. DJS]

Loggia ML, Berna C, Kim J et al. 2013. Disrupted brain circuitry for pain-related reward/punishment in fibromyalgia. Arthritis Rheum. [Nov 7 Epub ahead of print]. “In this study we investigate potential dysregulation of the neural circuitry underlying cognitive and hedonic aspects of the subjective experience of pain such as anticipation of pain and of pain relief….FMRI was performed on 31 FM patients and 14 controls while they received cuff pressure pain stimuli on their leg, calibrated to elicit a pain rating of ~50/100. During the scan, subjects also received visual cues informing them of impending pain onset (pain anticipation) and pain offset (relief anticipation)….Patients exhibited less robust activations during both anticipation of pain and anticipation of relief within regions commonly thought to be involved in sensory, affective, cognitive and pain-modulatory processes. In healthy controls, direct searches and region-of-interest analyses in the ventral tegmental area (VTA) revealed a pattern of activity compatible with the encoding of punishment: activation during pain anticipation and pain stimulation, but deactivation during relief anticipation. In FM patients, however, VTA activity during pain and anticipation (of both pain and relief) periods was dramatically reduced or abolished….FM patients exhibit disrupted brain responses to reward/punishment. The VTA is a source for reward-linked dopaminergic/GABAergic neurotransmission in the brain and our observations are compatible with reports of altered dopaminergic/GABAergic neurotransmission in FM. Reduced reward/punishment signaling in FM may relate to the augmented central processing of pain and reduced efficacy of opioid treatments in these patients.”

Martín J, Torre F, Padierna A et al. 2013. Interdisciplinary treatment of patients with fibromyalgia: Improvement of their health-related quality of life. Pain Pract. [Nov 27 Epub ahead of print]. “This interdisciplinary intervention has shown effectiveness in improving the HRQoL of this sample of patients with FM. The number of physical illnesses was identified as a predictor of that improvement.”

McKnite AM, Perez-Munoz ME, Lu L et al. 2012. Murine gut microbiota is defined by host genetics and modulates variation of metabolic traits. PLoS One. 7(6):e39191. “The gastrointestinal tract harbors a complex and diverse microbiota that has an important role in host metabolism. Microbial diversity is influenced by a combination of environmental and host genetic factors and is associated with several polygenic diseases. In this study we combined next-generation sequencing, genetic mapping, and a set of physiological traits of the BXD mouse population to explore genetic factors that explain differences in gut microbiota and its impact on metabolic traits. Molecular profiling of the gut microbiota revealed important quantitative differences in microbial composition among BXD strains. These differences in gut microbial composition are influenced by host-genetics, which is complex and involves many loci. Linkage analysis defined Quantitative Trait Loci (QTLs) restricted to a particular taxon, branch or that influenced the variation of taxa across phyla. Gene expression within the gastrointestinal tract and sequence analysis of the parental genomes in the QTL regions uncovered candidate genes with potential to alter gut immunological profiles and impact the balance between gut microbial communities. A QTL region on Chr 4 that overlaps several interferon genes modulates the population of Bacteroides, and potentially Bacteroidetes and Firmicutes-the predominant BXD gut phyla. Irak4, a signaling molecule in the Toll-like receptor pathways is a candidate for the QTL on Chr15 that modulates Rikenellaceae, whereas Tgfb3, a cytokine modulating the barrier function of the intestine and tolerance to commensal bacteria, overlaps a QTL on Chr 12 that influence Prevotellaceae. Relationships between gut microflora, morphological and metabolic traits were uncovered, some potentially a result of common genetic sources of variation.  Gut microorganisms may largely be determined by genetics.”

Mendy A, Vieira ER, Albatineh AN, et al. 2013. Low bone mineral density is associated with balance and hearing impairments. Ann Epidemiol Oct 29 [Epub ahead of print].  “Low BMD is associated with balance and hearing impairments, especially in older adults.”

Mifflin KA, Kerr BJ. 2013. The transition from acute to chronic pain: understanding how different biological systems interact. Can J Anaesth. [Nov 26 Epub ahead of print]. “Although pain is an adaptive sensory experience necessary to prevent further bodily harm, the transition from acute to chronic pain is not adaptive and results in the development of a chronic clinical condition. How this transition occurs has been the focus of intense study for some time. The focus of the current review is on changes in neuronal plasticity as well as the role of immune cells and glia in the development of chronic pain from acute tissue injury and pain….Our understanding of the complex pathways that mediate the transition from acute to chronic pain continues to increase. Work in this area has already revealed the complex interactions between the nervous and immune system that result in both peripheral and central sensitization, essential components to the development of chronic pain. Taken together, a thorough characterization of the cellular mechanisms that generate chronic pain states is essential for the development of new therapies and treatments.”

Moldwin RM, Fariello JY. 2013. Myofascial trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Curr Urol Rep. 14(5):409-417. “Myofascial trigger points (MTrP), or muscle "contraction knots," of the pelvic floor may be identified in as many as 85 % of patients suffering from urological, colorectal and gynecological pelvic pain syndromes; and can be responsible for some, if not all, symptoms related to these syndromes. Identification and conservative treatment of MTrPs in these populations has often been associated with impressive clinical improvements. In refractory cases, more "aggressive" therapy with varied trigger point needling techniques, including dry needling, anesthetic injections, or onabotulinumtoxinA injections, may be used, in combination with conservative therapies.”

Murray B, Yashar BM, Uhlmann WR et al. 2013. Ehlers-Danlos syndrome, hypermobility type: A characterization of the patients' lived experience. Am J Med Genet A. 161(12):2981-2988.  “Hypermobility type Ehlers-Danlos syndrome (EDS-HT) is an inherited connective tissue disorder clinically diagnosed by the presence of significant joint hypermobility and associated skin manifestations. This article presents a large-scale study that reports the lived experience of EDS-HT patients, the broad range of symptoms that individuals with EDS-HT experience, and the impact these symptoms have on daily functioning. A 237-item online survey, including validated questions regarding pain and depression, was developed. Four hundred sixty-six (466) adults (90% female, 52% college or higher degree) with a self-reported diagnosis of EDS-HT made in a clinic or hospital were included. The most frequently reported symptoms were joint pain (99%), hypermobility (99%), and limb pain (91%). They also reported a high frequency of other conditions including chronic fatigue (82%), anxiety (73%), depression (69%), and fibromyalgia (42%). Forty-six percent of respondents reported constant pain often described as aching and tiring/exhausting. Despite multiple interventions and therapies, many individuals (53%) indicated that their diagnosis negatively affected their ability to work or attend school. Our results show that individuals with EDS-HT can experience a wide array of symptoms and co-morbid conditions. The degree of constant pain and disability experienced by the majority of EDS-HT respondents is striking and illustrates the impact this disorder has on quality of life as well as the clinical challenges inherent in managing this complex connective tissue disorder.”

Nedergaard M. 2013. Neuroscience. Garbage truck of the grain. Science 340 (6140):1529-1530.  [This article focuses predominantly on neurodegenerative diseases, but the effect of the proposed glial cell network in clearing excess interstitial fluid from the brain is, I believe, very relevant to patients with fibromyalgia.  During or after the process of neurodegeneration, abnormal proteins can be difficult to process and remove from the brain. This is the case in Alzheimer’s disease, wherein tau and beta-amyloid can accumulate.  Cytosolic proteins may be released into the brain’s interstitial space, indicating that there may be a pathway for extracellular disposal of these neurotoxic wastes.  (This may also be a possibility for quinolinic acid, which can be produced instead of serotonin in the tryptophan kynurenine alternative metabolic pathway found in some fibromyalgia patients.)  There are aquaporin 4 (AQP4) channels on the vascular endfeet of astrocytes, a type of glial cell, that facilitate the flow from around the outsides of the arteries to the interstitial space.  The cerebrospinal fluid exchanges with the interstitial fluid, driving waste products from the arteries to the veins. The interstitial fluid flows around the veins to the lymphatic system in the neck area, and the material in the interstitial fluid eventually finds its way into the lymph system.  Up to 80% of the large proteins and soluble wastes and metabolic by-products in the brain are removed by this system of glial cells and lymph vessels working through the interstitial space.  Dr. Nedergaard calls this system in the brain the “glymphatic system”.  When AQP4 is dysfunctional or inappropriately located, as can occur after trauma or stroke (or perhaps exposure to quinolinic acid if the kynurenine metabolic pathway is in use) this can result in excess proteins, solutes and perhaps fluid accumulation. Perhaps defects in the glymphatic system could be part of the cause of fibrofog and cerebral fluid accumulation in fibromyalgia patients.  Excess interstitial fluid in the body has been observed in some fibromyalgia and insulin-resistant patients.  It is extremely difficult to rid the interstitial space of accumulated fluid.  The research being done by Dr. Nedergaard and others may offer insight and hope to some of us who have diffuse interstitial swelling and confusional states. DJS]

Ozel HE, Ozkiris M, Gencer ZK et al. 2013. Audiovestibular functions in noninsulin-dependent diabetes mellitus. Acta Otolaryngol. [Oct 16 Epub ahead of print]. “This study supports the proposition that vestibular dysfunction and sensorineural hearing loss (SNHL) may be considered among the complications due to noninsulin-dependent diabetes mellitus (NIDDM)….Hearing thresholds in all frequencies (except at 500 Hz for bone conduction) and SRS values were statistically significant in patients with NIDDM and control subjects, but there was no statistically significant difference according to the duration of the disease. Statistically significant alterations were present in VFT in patients with NIDDM compared with the control subjects.” 

Pontari M, Giusto L. 2013. New developments in the diagnosis and treatment of chronic prostatitis/chronic pelvic pain syndrome. Curr Opin Urol. 23(6):565-569. “Symptoms in men with chronic prostatitis/CPPS appear to cluster into a group with primarily pelvic or localized disease, and a group with more systemic symptoms. Several other chronic pain conditions can be associated with chronic prostatitis/CPPS, including irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome. Markers of neurologic inflammation and autoimmune disease parallel changes in symptoms after treatment. Treatment options include new alpha-blockers, psychological intervention, and prostate-directed therapy. The areas of acupuncture and pelvic floor physical therapy/myofascial release have received increased recent attention and appear to be good options in these patients. Future therapy may include antibodies to mediators of neurogenic inflammation and even treatment of bacteria in the bowel….The diagnosis of chronic prostatitis/CPPS must include conditions traditionally outside the scope of urologic practice but important for the care of men with chronic pelvic pain. The treatment is best done using multiple simultaneous therapies aimed at the different aspects of the condition.”

Rodrigo L, Blanco I, Bobes J et al. 2013. Clinical impact of a gluten-free diet on health-related quality of life in seven fibromyalgia syndrome patients with associated celiac disease. BMC Gastroenterol. 13(1):157. “Celiac disease (CD) is an autoimmune disorder, characterized by the presence of gastrointestinal and multisystem symptoms, which occasionally mimic those of Irritable Bowel Syndrome (IBS) and Fibromyalgia Syndrome (FMS). To assess the effectiveness of a Gluten-Free Diet (GFD) in seven adult female screening-detected CD subjects, categorized as severe IBS and FMS patients….Results of this pilot study show that the adherence to a GFD by CD-related IBS/FMS patients can simultaneously improve CD and IBS/FMS symptoms, and indicate the merit of further research on a larger cohort.”

Rodrigo L, Blanco I, Bobes J et al. 2013. Remarkable prevalence of celiac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study. Arthritis Res Ther. 15(6):R201. “The findings of this screening indicate that a non-negligible percentage of IBS/FMS patients are CD patients, who can improve symptoms and possibly prevent long-term CD-related complications with a strict lifelong GFD.”

Rowe AH, Xiao Y, Rowe MP et al. 2013.  Voltage-gated sodium channel in grasshopper mice defends against bark scorpion toxin. Science. 342(6157):441-446. “Painful venoms are used to deter predators. Pain itself, however, can signal damage and thus serves an important adaptive function. Evolution to reduce general pain responses, although valuable for preying on venomous species, is rare, likely because it comes with the risk of reduced response to tissue damage. Bark scorpions capitalize on the protective pain pathway of predators by inflicting intensely painful stings. However, grasshopper mice regularly attack and consume bark scorpions, grooming only briefly when stung. Bark scorpion venom induces pain in many mammals (house mice, rats, humans) by activating the voltage-gated Na(+) channel Nav1.7, but has no effect on Nav1.8. Grasshopper mice Nav1.8 has amino acid variants that bind bark scorpion toxins and inhibit Na(+) currents, blocking action potential propagation and inducing analgesia. Thus, grasshopper mice have solved the predator-pain problem by using a toxin bound to a nontarget channel to block transmission of the pain signals the venom itself is initiating.”

Scarpina F, Van der Stigchel S, Nijboer TC et al. 2013. Prism adaptation changes the subjective proprioceptive localization of the hands. J Neuropsychol. [Nov 13 Epub ahead of print]. “Prism adaptation involves a proprioceptive, a visual and a motor component. As the existing paradigms are not able to distinguish between these three components, the contribution of the proprioceptive component remains unclear. In the current study, a proprioceptive judgment task, in the absence of motor responses, was used to investigate how prism adaptation would specifically influences the felt position of the hands in healthy participants. The task was administered before and after adaptation to left and right displacing prisms using either the left or the right hand during the adaptation procedure. The results appeared to suggest that the prisms induced a drift in the felt position of the hands, although the after-effect depended on the combination of the pointing hand and the visual deviation induced by prisms. The results are interpreted as in line with the hypothesis of an asymmetrical neural architecture of somatosensory processing. Moreover, the passive proprioception of the hand position revealed different effects of proprioceptive re-alignment compared to active pointing straight ahead: different mechanisms about how visuo-proprioceptive discrepancy is resolved were hypothesized.” Abnormal visual prisms affect proprioceptive sense.

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

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

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


Sommer C. 2013.  [Neuropathic pain: Pathophysiology, assessment, and therapy.] Schmerz. [Nov 13 Epub ahead of print]. [Article in German] “Neuropathic pain is caused by lesions in the somatosensory system. Characteristic but not exclusive features are spontaneous burning pain, electrifying and shooting pain, hyperalgesia, and allodynia. The basic concept of the pathophysiology of neuropathic pain is the combination of peripheral and central sensitization. Knowledge on the molecular mechanisms has grown exponentially in recent years. The problem lies in identifying the individual mechanisms and in determining a comprehensive concept. Progress has also been made in assessment, e.g., methods for detecting dysfunction of nociceptors have significantly improved. In addition, there are many more therapeutic options available than 15 years ago. The drugs available include antidepressants, anticonvulsants, opioids, and topical medications.” 

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

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

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

Stephan AH, Madison DV, Mateos JM et al. 2013. A dramatic increase of C1q protein in the CNS during normal aging. J Neurosci. 33(33):13460-13474. “The decline of cognitive function has emerged as one of the greatest health threats of old age. Age-related cognitive decline is caused by an impacted neuronal circuitry, yet the molecular mechanisms responsible are unknown. C1q, the initiating protein of the classical complement cascade and powerful effector of the peripheral immune response, mediates synapse elimination in the developing CNS. Here we show that C1q protein levels dramatically increase in the normal aging mouse and human brain, by as much as 300-fold. This increase was predominantly localized in close proximity to synapses and occurred earliest and most dramatically in certain regions of the brain, including some but not all regions known to be selectively vulnerable in neurodegenerative diseases, i.e., the hippocampus, substantia nigra, and piriform cortex. C1q-deficient mice exhibited enhanced synaptic plasticity in the adult and reorganization of the circuitry in the aging hippocampal dentate gyrus. Moreover, aged C1q-deficient mice exhibited significantly less cognitive and memory decline in certain hippocampus-dependent behavior tests compared with their wild-type littermates. Unlike in the developing CNS, the complement cascade effector C3 was only present at very low levels in the adult and aging brain. In addition, the aging-dependent effect of C1q on the hippocampal circuitry was independent of C3 and unaccompanied by detectable synapse loss, providing evidence for a novel, complement- and synapse elimination-independent role for C1q in CNS aging.” [The microglial cells that help prune developing brain cells early in life may be part of the problem of aging.  Dysfunctional glial cells could be responsible for some of the symptoms of fibromyalgia that seem to be an advanced aging process. If so, the ability of this C1q deficient mouse may hold some clues to a work-around of fibromyalgia cognitive deficits in the future. DJS]

Thomas K, Shankar H. 2013. Targeting myofascial taut bands by ultrasound. Curr Pain Headache Rep. 17(7):349.  “Myofascial pain syndrome (MPS) is a frequent diagnosis in chronic pain and is characterized by tender, taut bands known as trigger points. The trigger points are painful areas in skeletal muscle that are associated with a palpable nodule within a taut band of muscle fibers. Despite the prevalence of myofascial pain syndrome, diagnosis is based on clinical criteria alone. A growing body of evidence that suggests that taut bands are readily visualized under ultrasound-guided exam, especially when results are correlated with elastography, multidimensional imaging, and physical exam findings such as local twitch response. The actual image characteristic in B mode appears to be controversial. Ultrasonography provides an objective modality to assist with diagnosis and treatment of trigger points in the future.” [Presently, this imaging is only available in a few select research settings, and is extremely expensive.  DJS]

Vilar B, Busserolles J, Ling B et al. 2013. Alleviating Pain Hypersensitivity through Activation of Type 4 Metabotropic Glutamate Receptor. J Neurosci. 33(48):18951-18965.  “Hyperactivity of the glutamatergic system is involved in the development of central sensitization in the pain neuraxis, associated with allodynia and hyperalgesia observed in patients with chronic pain. Herein we study the ability of type 4 metabotropic glutamate receptors (mGlu4) to regulate spinal glutamate signaling and alleviate chronic pain. We show that mGlu4 are located both on unmyelinated C-fibers and spinal neurons terminals in the inner lamina II of the spinal cord where they inhibit glutamatergic transmission through coupling to Cav2.2 channels. Genetic deletion of mGlu4 in mice alters sensitivity to strong noxious mechanical compression and accelerates the onset of the nociceptive behavior in the inflammatory phase of the formalin test. However, responses to punctate mechanical stimulation and nocifensive responses to thermal noxious stimuli are not modified. Accordingly, pharmacological activation of mGlu4 inhibits mechanical hypersensitivity in animal models of inflammatory or neuropathic pain while leaving acute mechanical perception unchanged in naive animals. Together, these results reveal that mGlu4 is a promising new target for the treatment of chronic pain.”

Weiss S, Winkelmann A, Duschek S. 2013. Recognition of facially expressed emotions in patients with fibromyalgia syndrome. Behav Med. 39(4):146-154. “Thirty-five FMS patients and 35 healthy controls accomplished a face recognition task. Additionally, pain severity, alexithymia, depression, anxiety, psychiatric co-morbidity and medication use were assessed. The patients displayed reduced task performance in terms of more misclassifications of emotional expressions than controls. Pain severity, alexithymia, depression and anxiety were inversely related to recognition performance, with pain severity accounting for the largest portion of test score variance. Psychiatric co-morbidity and medication had no impact on performance. The study documented impaired emotion recognition in FMS, which may contribute to the interpersonal difficulties and reduced social functioning related to this condition.”

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