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Myofascial Pain and Fibromyalgia




Airaksinen O. Vanninen E, Hemo A, Kuikka J, Hanninen O, Pontinen PJ, Tanskanen A, Tiihonen J. Depts of Physical and Rehabilitation Medicine and Clinical Physiology, Kiiopio Univ Hospital, FIN 702 10 Kuopio Finland.

Aims: Fibromyalgia is a syndrome of widespread pain. The aim of this study was to evaluate the regional cerebral perfusion offibro-myalgia patients compared to painfree subjects.

Methods: 27 patients with mean age of 47 2 years (two men, 25 women) clinically diagnosed fibromyalgia according the criteria published by American College of Rheumatology in 1990. The control group consisted of 10 healthy subjects with mean age of 40 3 years. Regional cerebral perfusion was measured by using 99mTc-ethyl-cysteine-dimer and SPECT. The imaging resolution was 7-8 mm. A semi-automatic brain quantification program of Siemens was used to analyse the regions of interest. All analyses were performed by the same observer blinded to the clinical data of the subjects.

Results: The mean 99mTc-ECD doses were 560 4, and 548 4 MBq for the fibromyalgia and control groups, respectively (NS). The fibromyalgia group had significantly lower perfusion bilat-erally in thalamus and frontal cortex than the control group. Also in nucleus caudatus on the right side there was a significant decrease compared to control group.

Conclusion: Our findings suggested that there will be a decrease of regional cerebral perfusion connected to chronic pain.


Ulla Maria Anderberg*. Zhurong Liu**, Lars Berglund***, Kerstin Uvnas-Moberg****, Fred Nyberg**. *Dept ofNeurosci-ence, Psychiatry and Pain Center, Univ Hospital, SE-75185 Uppsala, **Dept of Pharmaceutical Biosciences, Uppsala Univ, Uppsala, ***Dept of Public Health and Caring Sciences, Uppsala Univ, Uppsala, ****Dept of Pharmacology and Physiology, Karo-linska Inst, Stockholm and Dept of Animal Physiology, Swedish Univ of Agriculture Sciences, Uppsala, Sweden.

Aim of Investigation: To assess the neuropeptides neuropeptide Y (NPY), nociceptin and oxytocin in plasma of female fibromyalgia syndrome (FMS) patients in different phases of the menstrual cycle and pre- and postmenopausally, and relate these peptides to pain and other symptoms in female FMS patients.

Methods: Twenty-three patients and 17 control subjects (for oxytocin there were 39 patients and 30 control subjects) were divided into pre-and postmenopause and the premenopausal women were also divided into follicular and luteal phases of the menstrual cycle, in which plasma for assessment of the levels of the different neuro-peptides were drawn. The patients were also registering pain and other symptoms during 28 days. Correlation between the levels of the neuropeptides and the symptoms were also made.

Results: The levels of all of the three neuropeptides were perturbed compared to the controls. Patients in luteal phase of the menstrual cycle and postmenopausal patients seem to be most sensitive regarding NPY and nociceptin. The levels of oxytocin were decreased in depressed FMS patients and in high scoring pain and stress subgroups of patients. A positive correlation between NPY and physical symptoms, and a negative correlation between oxytocin and depression and anxiety were found.

Conclusion: The perturbed neuropeptide levels found in the hor-monally different subgroups and in depressed FMS patients and the relation to certain symptoms in these patients suggest that there are links between the female sex hormones and pain processing pep-tides as well as to the stress axes and monoaminergic systems. The results may be of importance to explain some of the pathophysi-ological mechanisms behind the FMS.

Acknowledgment: Supported in part by grants from the Swedish Health Insurance System, the Uppsala County Council and the Swedish Medical Research Council nr 9459.


Frederique Barbot. Eric Serra, Pain Relief Unit, CHU Amiens, France

Aim of Investigation: Ahles, Yunus and Masi showed that fibromyalgia is not a form ofdepresion. According with these findings, we want to investigate the relationship between Somatization and fibromyalgia (FM). Are symptoms of fibromyalgia a form ofso-matization?

Methods: We compare a group of 30 patients with fibromyalgia according to the American College of Rheumatology criteria and a group of 30 patients with polyarthritis painful for more than 6 months. We use different tools to evaluate pain (Analogic Visual Scale, body diagram and a french adaptation ofMcGill pain Ques-tionnary), depression (HAD questionnary) and somatization (DSM-3-R criteria).

Results: First results on 40 patients (38 women and 2 men) show an excess ofFM diagnosis: 29 FM confirmed from 41 FM suggested (27 women and 2 men). Mean age at time of evaluation was 47 years and 5 months (25 to 66 years old). The score of somatization seems to be high: 28 of the 40 patients and 23 of the 29 FM (22 women and 1 man). The polyarthritis group is under constitution with no results available yet.

Conclusions: Fibromyalgia might be a form of somatization, but fibromyalgia and somatization have similar symptoms as headache, back pain or muscular weakness and might link up with to a process ofmedicalization of individual suffering.


L. Barras. E. Masquelier, Pain Unit, PM&R Dept, Clinique Saint-Pierre, Belgium.

Aim of Investigation: What is the best deconditionning index in women with Fibromyalgia Syndrome (FS).

Methods: Ten nonrandomnized consecutive women seen in our PM&R out patient Dept for FS (mean age: 42.yrs) according to the ACR-criteria and ten control healthy women (mean age: 42.8 yrs) were included in the study. A submaximal exercise test was carried out on a cycle ergometer Monark 818 E with a initial workload of 25 Watts followed by stepwise increments of 25 Watts every 2 minutes until exhaustion. During the test, the degree of perceived exertion was recorded to a 0-10 modified Borg scale. Heart Rate (HR) was monitored with a Polar Sport Tester and the pain was scored on a Visual Analogue Scale (VAS). The fitness index for each woman was assessed using the Working Capacity Index (W65%/kg). The W65%/kg at HR65% was interpolated on the basis of the calculated work intensity/HR relationship.

Results: There are no difference in HR adaptation between the two groups. The slope of the relationship between workload and HR is similar for the two groups. The Working Capacity Index is no statistically different for FS and control groups (CT65%/kg: 1.54 vs. 1.60 and mean weight: 68.8kg vs. 59.2kg). For a same workload, FS women have higher perceived exertion than control women. The difference is statistically significant (P<0.05).

Conclusion' Surprisingly, the Working Capacity Index is normal, suggesting that HR adaptation ofFS patients may be normal. On the other hand, perceived exertion is significantly elevated for FS women. This finding might be explained by central factors, by musculo-skeletal tissues sensitization and by cognitive or emotional processes The authors propose the use of the Borg scale and the category 4 (somewhat strong) and 5 (strong) for rehabilitations programs in FS women population


Sidney Benjamin. Stella Moms, John McBeth, Gary Macfarlane, Alan Silman, Ai-thntis Research Campaign Epidemiology Unit, Stopford Building, Univ of Manchester, Manchester, Ml 3 9PT, UK

Aim of Investigation To determine whether people in the general population with chronic widespread pain (CWP) have more mental disorders and somatisation than those without CWP Method: A population sample aged 18-65 years was assessed with regard to pain status (CWP, other pain, no pain) The 12-item General Health Questionnaire (GHQ) was used to screen for mental disorders. Somatisation was assessed using 5 questionnaire measures A random sample of GHQ high-scorers was interviewed using the Present State Examination to diagnose mental disorders The association of CWP and mental disorders was modelled using logistic regression, adjusting for possible confounders, including non-response.

Results: 1953 (75%) subjects completed the questionnaire assessment 301 subjects sconng >1 on the GHQ were interviewed The overall prevalence of mental disorders was estimated to be 11 2% The odds of having a mental disorder with CWP was 3 14 (95% CI 1.74-5.64). Most diagnoses were mood and anxiety disorders, with few somatoform disorders. Assessments of somatisation were similar in people with CWP but no mental disorder, those with CWP plus mental disorder, and those with mental disorder but not CWP

Conclusions. In the general population about 20% of people with CWP have a mental disorder, based on standardised interviews and classification. The nsk, although increased, is less than in some reports based on clinical samples. The majority do not have mental disorders. They do, however, show multiple characteristics of somatisation People with CWP should be screened for these disorders and treated accordingly

Acknowledgments: Supported by Arthritis and Rheumatism Campaign grant S0542


Birgitta Berglundn, Eva-Liz Hanuntf. Eva Kosek, and UlfLind-blom, The Dept of Rehabilitation Medicine and Dept of Clinical Neurosciences, Section of Neurology, Karolinska Inst, Karolinska Hospital; and ainst of Environmental Medicine, Karolinska Inst and Dept of Psychology, Stockholm Univ, S-106 91 Stockholm, Sweden

Aim of Investigation: To study absolute threshold, perceived intensity and perceived quality of thermal (and tactile) stimulations in patients with fibromyalgia.

Methods: Nine women (mean age 47 yrs) were tested in two pain areas and at thenar. Absolute thresholds and perceived intensity were determined by the method of limits and free number magnitude estimation, respectively. Perceived quality was assessed by verbal descriptors.

Results The test-retest reliability was good for all patients The cold thenar thresholds were lower in fibromyalgia patients than in unaffected controls. All patients reached thresholds for cold-pain and cold-pain tolerance above 10C in the pain areas and at thenar This rarely occurred in unaffected controls (or neuropathic pain patients) Psychophysical power functions for perceived intensity fitted the data well for all test sites The thenar-function exponents were normal (1 5 for warmth, 1 2 for cold, 0 3 for touch) in comparison with unaffected controls (1 6 for warmth, 1 1 for cold) and neuropathic-pam patients (1 7 for warmth, 1 0 for cold, 0 4 for touch), perceived quality was also correctly classified In pain areas, all fibromyalgia patients reported aberrant perceived qualities for cold but normal for warmth and touch

Conclusions Two abnormalities stand out among the results (1) The facilitation of the cold and possibly the cold pain sensory channels This may be generic for fibromyalgia. (2) The aberrant perceptions for cold in the pain areas Another main finding was that the psychophysical functions for touch, cold, and warmth (mcl heat pain) apparently are normal in fibromyalgia Awaiting a larger study sample the results are to be viewed as preliminary

Acknowledgments The research was supported by the Swedish Foundation for Health Care Sciences and Allergy Research


LA Bradley. A Sotolongo*, GS Alarcon*, JM Mountz*, KR Alberts*, HG Liu*, BC Kersh*, DF DeWaal*, NR Palardy*, L Cian-frmi*, Dept of Medicine, Univ of Alabama at Birmingham, Birmingham, AL, 35294, USA

Aim of Investigation To measure change in brain rCBF produced by acute mechanical pain in FM patients and healthy controls

Method 7 right-handed women who met American College of Rheumatology criteria for FM (mean age = 49 2 3 yrs) and 6 right-handed, healthy women (mean age =41 3 6 yrs) underwent pain threshold assessment, brain magnetic resonance imaging, and single photon emission computed tomography (SPECT) with Tc-99m HMPAO tracer of brain rCBF under resting conditions They then underwent brain SPECT during a 5-mmutc period of phasic, painful dolonmeter stimulation of 3 right-side tender points (lower cervical, trapezius, 2nd nb) at 3 kg pressure above their respective pain threshold levels The rCBF values for regions of interest (ROI) were semi-quantitated and normalized to the whole slice Pain-induced rCBF change in ROIs for each subject group was evaluated by one-tailed, paired t-tests Subject groups' pain thresholds were compared by one-tailed, Student's t-test

Results FM patients' mean pain threshold (2 9 2) was significantly (p < 001) lower than that of controls (4 9 3) Both patients (p = .05) and controls (p = .01) showed a significant increase in left somatosensory (SS) cortex rCBF dunng acute pain Only controls showed a significant (p =.04) increase in left thalamus with acute pain However, only patients showed significant increases dunng acute pain in nght SS cortex (p = 03) and in AC cortex (p = .05)

Brain ROI
Left SS Cortex
Right SS Cortex
Left Thalamus
AC Cortex

Conclusions. 1) Both FM patients and controls show expected activation ofcontralateral SS cortex dunng acute pain, 2) Only controls show expected activation ofcontralateral thalamus with pain, 3) Despite receiving relatively low intensity dolonmeter stimulation, only patients show activation of AC cortex and unexpected activation of nght SS cortex; 4) FM patients' activation patterns are similar to those in patients with cluster headaches and atypical facial pain and may contnbute to the sensitivity to numerous noxious stimuli shown by FM patients

Acknowledgment: Grant 2 P60 AR-200614-22, NIH


G. Carii*. A.L. Suman*, F. Badii**, G. Di Piazza0, G. Biasi**, V. Bachiocco P.Castrogiovanni and R. Marcolongo**, *Dept. of Physiology, **Dept. of Rheumatology, Dept. of Psychiatry, "Univ of Siena, and Dcpt. of Anaesthesia and Rehanimation, S. Orsola, Bologna, Italy.

Aim of Investigation: To identify the possible differences between patients with diffuse musculoskeletal pain who meet (FM) and do not meet (NFM) the criteria for fibromyalgia.

Methods: Patients were recruited from the Rheumatology Clinic and submitted to a protocol of experimental stimuli (von Frey, electrocutaneous stimulation, cold pressure test, submaximum effort tourniquet technique, heat and cold nociceptivc stimuli), self-administered questionnaires (MAPS: Multidimcntional Affect and Pain Scale; STAI-Y: State Trait Anxiety Inventory; SCL-90: Symptom Check List-90; PLOCS: Pain Locus of Control Scale; TAS 20: Toronto Alexithymia Scale), an epidemiological interview and a structured clinical interview (SC1D, DSM-III-R).

Results:VAS was higher in FM than in NFM. Moreover following electrocutaneous stimulation, FM displayed pain threshold, at lower value than NFM. The analysis of MAPS showed that FM had higher scores on Sensory Qualities of pain and lower scores on Well Being than NFM. As for SCL-90, the general scores of Symptoms Severity and Symptoms Diversity were much higher in FM than NFM; anxiety, somatization and depression displayed higher scores in FM than NFM, also the scores ofSTAI Y-1 and Y-2 were much higher in FM than in NFM.

Conclusions: The fibromyalgia represents a discrete entity in patients with chronic diffuse musculoskeletal pain.


, D.J. Clauw. F. Petzke, K. Ambrose , B. K. Roberts and R.H.Gracely2. Dept of Medicine, Rheumatology, Georgetown Univ Medical Center, Washington D.C. 20007; "Clinical Measurement and Mechanisms Unit, PNMB, NIDCR, NIH, Bethesda, MD, 20892, USA.

Aim of Investigation: Most studies measure tenderness with a dolo-rimeter or algometer, using an ascending Method of Limit design. Both patient and observer expectancy effects may cause an increased response in such paradigms. Random testing paradigms reduce this confounding factor. In this study we compared pressure pain testing using an ascending and random paradigm, to determine if persons with FM might show a lower pain threshold primarily because of psychological mechanisms relating to the anticipation of pain.

Methods: 39 patients with FM and 20 age and gender matched HC were tested. Discrete, rectangular pressure stimuli of 5sec duration were applied to both thumbnails (contact area 1 cm'). Ascending stimuli were applied in 0.45-kg increments up to 4.54 kg (ASC). A set of 7 stimuli was repeated twice and presented randomly (RAN). Pain intensity (PI) was recorded with a combined numerical analog descriptor scale and reported as area under curve.

HC 19.32.56 37.6 5.9 18.34.8 4 (19%) 17 (81%)
FM 53.2 ±15.2 69.94.7 16.5±3.5 7 (17.9%) 32 (82.1%)

Results: As expected, FM had significantly higher PI ratings (p<0.0001). Interestingly, both groups showed significantly lower PI ratings for RAN than ASC (pO.001), with a similar absolute difference (RAN-ASC, p=0.76). A 3-way-ANOVA showed significant effects for group (p<0.0001), stimuli intensity (p<0.0001), and method (p<0.0001), but no significant interaction. The individual distribution of "expectancy" (ASC>RAN) versus "no expectancy" (ASC<RAN) was the same for the two groups (p=0.92).

Conclusions: These data suggest that the increased pressure pain sensitivity in FM patients can be reliably evaluated in both simple and complex measurement protocols. FM patients showed no specific expectancy effect.


Christian Couppe*. Asbj0m Midttun, Jorgen Hilden*, Uffe Jorgensen*, Peter Oxholm*, Anders Fuglsang-Frederiksen*, Dept. of Ortopaedic Surgery, Rcumatology & Clinical Neurophysiology, Gcntofte Hospital, 2900 Hellerup, DK & Dept. of Biostatistics, Univ of Copenhagen. DK

Aim of Investigation: Treatment ofmyofascial pain syndromes arising from myofascial triggerpoints is clinically well established although few studies have given tentative describtions of the local structural and functional abnormalities of triggerpoints. This is not well understood. The purpose of the study was to investigate EMG activity in triggerpoints in a blinded fashion.

Methods: 19 young subjects with chronic light to moderate shoulder and arm pain had a triggerpoint (tender point) in the m. infra-spinatus, where manual pressure produced a characteristic referred pain pattern. A physical therapist palpated and code-marked this point and a control point (non-tender point) in the same muscle. A neurophysiologist who was blinded, made 20 systematic concentric needle EMG registrations around both points in the relaxed muscle. The critieria used determining spontaneous EMG activity was that activity in the adjacent channel remained silent. Results: There were significantly more subjects with spontaneous EMG activity in triggerpoints compared with control points (Student: p<0,02). The spontaneous activity in the triggerpoints was interpretated as endplate noise and /or spikes. When present, it's amplitude (root mean square amplitude) was also higher (though not significantly) activity of the same kind seen in control points.

Conclusion: Our study shows spontaneous EMG activity in myofascial triggerpoints suggestive ofendplates. Acknowledgments: Supported in part by the Danish physical therapy research Grant.


F.I. Devlikamova*. L.F. Kasatkma*, F.A. Khabirov* (SPON: DG Simons) Dept of Neurology, Kazan Medical Academy, 13 Vatutin St., Kazan, Tatarstan, 420022, Russia.

Aim of Investigation: The present studies were designed to investigate whether the neuromuscular dysfunction in the immediate vicinity of a motor endplate would be the anatomical substrate of a myofascial trigger point (TrP) region.

Methods: Twenty-five patients with the myofascial pain syndrome, mean age 33.6 years, SD 9.6, were included in this study. Control data were obtained from 20 healthy subjects (mean age 35.2, SD 8.8). The brachioradialis muscle was examined by means of single fiber electromyography (SFEMG) in the motor point and myofascial TrP (Keypoint, Denmark). The patients slightly activated the muscle under study. Mean values of consecutive differences (MCD) of 10 interpotential intervals were calculated to expressed the "neuromuscular jitter".

Results: SFEMG is of great value in demonstrating or excluding abnormalities in the disease of nerves, muscles, or the neuromuscular junction and reflects even the slight rearrangements within the motor unit. MCD of TrP is higher than that in control group with a significant difference (PO.05). The fiber density was increased in the brachioradialis muscle, in the TrP region (2.05, SD 0.26; control - 1.48, SD 0.3, PO.01).

Conclusions: Jitter shows the changes in the neuromuscular transmission of end-plates in TrP. The fiber density is increased in myo-fascial TrPs of all the brachioradialis muscles in the patients with the myofascial pain syndrome and serves an early sign of motor unit reorganisation.


B.G.Doenng, I. Yegiil, E. Erhan, M. Uyar, Dept ofAlgology, Ege Univ, Medical School, Izmir, Turkey

Aim: The Minnesota Multiphasic Personality Inventory (MMPI) is the most widely used measure for personality assesment of chronic pain patients (Hataway and Me Kinley, 1940). Four different pain patients were classified in previous studies (Guck et al. 1988;Stembach, 1974). The first subgroup was classified as the "conversion V" profile. Ego Strenght, Manifest Anxiety, Somatization were investigated with slightly higher Hypochandriasis (Hs), Hysteria (Hy), scale's t scores compared to Depression on "conversion V" profile as personality characteristics in our fibromyalgia patients. Correlation between Hy, Hs, D and Somatization, Ego Strenght, Manifest Anxiety scales were searched and studied in this group.

Method: MMPI, Ego Strenght (ES) (Ban-on, 1953), Manifest Anxiety Scale (MAS) (Taylor, 1951), Somatization scale (Stein, 1968), from the approach scales of the MMPI were used. The subjects for this study were 30 fibromiyalgia patients participated from Algol-ogy Clinic of Ege Univ. SPSS was used for the statistical analysis. Results: The MMPI mean profile of these 30 patients' t scores between 50-70 were found in this study. The average mean oft scores ofHs is 67, Hy is 66, D is 58. The correlation between ES scale and MAS was found significantly negative (r=-0.4128; p=0.023). The correlation between MAS and Somatization scale was found significantly positive (r=0.5956; p=0.001). The correlation between MAS and Depression scale was found significantly positive (r=0.6963; p=0.000). The correlation between Somatization scale and Hs, Hy were found significantly positive (r=7733; p=000), (r=4534;p=0.12).

Conclusion: It was found that the Hs and Hy scores were slightly higher than the depression scale on a "conversion V" profile. As a result the Hy and Hs t scores did not significantly increase in fibromiyalgia patients. This suggests that elevations in our fibromiyalgia patients were not not clinically significant. Different personality characteristics must be searched in these group studies because the mean MMPI profile does not indicate pathological profile in the group. Our results indicate that patients with fibromiyalgia have shown slightly higher Somatization comparing to depression and anxiety. The patients with high ES scores have lower anxiety scores than the others. ES, MAS, Somatization approach scales can be useful in clinical practice distinguish chronic pain patients.


S. F. Dworkin. J. Turner, K. H. Huggms*, D. Massoth*, L. Wilson*, L. Manci*, E. Truelove, U. of Washington, Dept. of Oral Medicine, Seattle, WA 98195-6370 (USA)

Aim of Investigation: Two randomized clinical trials (RCTs) were conducted to determine if tailoring treatment by grade of chronic pain dysfunction, independent of physical diagnosis, is effective for temporomandibular disorder (TMD) pain. The present RCT compared usual TMD care to a comprehensive biobehavioral treatment regimen integrating CBT with usual treatment for poorly functioning TMD cases.

Methods: Subjects were 118 TMD clinic cases defined as psycho-socially dysfunctional using the Graded Chronic Pain (GCP) Scale. The GCP is a 0-IV severity scale based on pain intensity, pain-related interference and pain disability days. Cases identified as II-High, III and IV were defined as psychosocially dysfunctional and randomly assigned to usual treatment by a dentist TMD specialist or to CBT, a 6-session psychologist-delivered intervention integrated with usual care, aimed at reducing pain levels and related psychosocial interference and at enhancing self control pain coping. Post-treatment covariance analyses compared usual treatment and CBT after adjusting for baseline levels. A 1-yr. follow up is under way.

Results: Intent-to-treat (ANCOVA) analyses showed significantly lower mean levels for CBT (n=49) compared to usual treatment (n=52), for pain intensity (4.4 vs. 5.6, p<03), days in pain (15.9 vs. 19.8, p<04) and pain interference (3.2 vs. 4.3, p<03). CBT also showed significantly greater perceived control over pain and satisfaction with comprehensive care.

Conclusions: A comprehensive treatment program addressing psychological and behavioral factors was more effective than usual care alone for reducing post-treatment TMD pain and its impact independent of TMD diagnosis. This supports targeting treatment to level of psychosocial adaptation to chronic TMD pain. Acknowledgments: Supported by NIH Grant DEI 0766


Malin Emberg. Thomas Lundeberg1, Sigvard Kopp3, Depts of Clinical Oral Physiology and Physiology5, Karolinska Inst, 141 04 Huddinge, Sweden

Aim of Investigation: To investigate the effect of 5-HT on pain and allodynia in the masseter muscle in a randomized controlled and double blind study.

Methods: Twelve female patients with fibromyalgia (FM) and 12 age matched female healthy individuals (HI) participated. The subjects scored their pain (VAS) from the masseter muscles and the pressure pain threshold (PPT) was recorded (basal values). 0.2 ml 5-HT (10-7, 10-5, or 10-3 M) was then randomly injected into one of the masseter muscles in a double-blind manner. The contralat-eral masseter muscle received isotonic saline. VAS and PPT were recorded 10 times during 30 min after injection. Injections were repeated after 1 and 2 weeks with 5-HT in the other concentrations. The study was approved by the local ethics committee at Huddinge hospital, Sweden.

Results: There was a dose dependent effect of 5-HT in the Hl-group. Both 10-5 M and 10-3 M caused a significantly greater decrease of PPT than saline (mean difffor all recordings, Wilcoxon). 5-HT at a concentration of 10-3 M caused a significantly greater increase of VAS than saline (median difffor all recordings, Wilcoxon). In the FM-group there was no significant difference between 5-HT and saline for any variable. Conclusions: This study shows that injection of 5-HT into the masseter muscle of healthy individuals causes pain and allodynia in a dose dependent manner, while no such response occur in patients with FM.

Acknowledgments: This study was supported by grants from the Swedish Dental Society.


Mariam Garifianova. Evgeni Demidov*, Dept of Neurology, Kazan Medical Academy, Kazan, Tatarstan, 420012, Russia.

Aim of Investigation: To study the pathogenesis ofmyogenic trigger points (MTPs) in patients with hemifacial spasm (HFS).

Methods: The neurologic examination and magnetic resonance imaging (MRI) were made in 6 patients with typical HFS. The blink reflex and needle EMG ofmusculus orbicularis oris were investigated on the electromyograph "Counterpoint" [Dantec, Denmark]. The small pieces of mimetic muscles obtained by the needle biopsy were studied on the electron microscope "Gem -7" by traditional methods

Results In 6 patients with HFS the complication of Bell's palsy was observed in 3 They had mild facial weakness on the involved side MRI was normal In comparison with controls the increased latency of R 1 component and high exitability of R2 component of blink reflex were registered (P< 0,05 by Student) The needle EMG revealed both myopathic and neuropathic changes The mitochon-dna of high density were found by ultrastructure examination Conclusions On the basis of this data we conclude that patients with Bell's palsy have a high probability of HFS The disturbance ofneurotrophic control may be the cause ofalgesic trigger points in the mimetic muscles The trigger zone in the facial nerve was considered as a cause of the burst of involuntary dome and tonic activity of mimetic muscles due to high exitability of the segmental and suprasegmental structures This data may emerge as the key to treatment


Chris Hennksson, Ulla Carlberg, The Pain and Rehabilitation Centre, Univ Hospital, Linkoping, Sweden

Aim of Investigation: To evaluate programmes of different length, organisation and content in relation to results and benefits for patients with fibromyalgia

Methods: Data were collected from 200 patients with a diagnosis of fibromyalgia The patients attended one of four different programmes organised by three different health care institutions The length of the programmes vaned from 3 days, 8 weeks, 6 weeks, to 6 months Data included medical examination with tender point count, general questionnaire including an 8 day-diary, FIQ, SF-36, Self-Efficacy Scale, Coping Strategy Questionnaire, Quality of Life Scale Patients also gave a subjective evaluation of the programme Data were collected at the beginning and end of each programme and one year after the programme

Results: Data for 180 patients before and after the programme are now available The data collected one year after the programme are not complete but about V, of the data will be collected before summer 1999 The data are being analysed and results will be presented at the Congress There is a large variation between patients with fibromyalgia in their need of information and support The different programmes will be presented and discussed from a cost-efficacy perspective.

Conclusions: Multi-professional educational programmes have been reported to be successful Clinical experience shows that most patients benefit from being treated in groups where everyday problems can be discussed from the patients' perspective Evaluation of different programmes is essential in order to gain more knowledge about the optimal effect of resources Acknowledgments The National Board of Health and Welfare, Sweden has supported this study


K. H. Huggms*. S. F. Dworkin, J. Turner, L. Wilson*, D. Mas-soth*, M. Lane*, L. Manci*, E Truelove, U. of Washington, Dept. of Oral Medicine, Seattle, WA 98195-6370 (USA)

Aim of Investigation' Two randomized clinical trials (RCTs) were conducted to determine if tailoring treatment by grade of chronic pain dysfunction, independent of physical diagnosis, is effective for temporomandibular disorder (TMD) pain. The present RCT compared usual TMD care by a dentist to a self-management (SM) intervention for TMD patients maintaining adequate levels ofpsy-chosocial function

Methods: Subjects were 124 TMD patients defined as psychoso-cially functional using the Graded Chronic Pain (GCP) Scale. The GCP is a 0-IV seventy scale based on pain intensity, pain-related interference and pain disability days Patients identified as I and II-low interference were defined as psychosocially functional Random assignment was to usual treatment by a dentist-TMD specialist or to a 3-session dental hygienist (RDH) delivered intervention (in lieu of usual treatment) involving skills training and education to monitor and self-manage signs and symptoms of TMD Post-treatment covanance analyses compared usual treatment and SM controlling for baseline level A 1-yr follow up is under way

Results Intent-to-treat ANCOVA showed significantly lower mea levels for SM (n=50) compared to usual treatment (n 57), for pain intensity (2 1 vs 3 3, p< 01) and hours per day in pain (3 9 vs 6 2, p< 05) Enhanced perceived control of pain and greater satisfactioi with care were observed for SM (p's < 003) No differences were found in range of jaw opening measures (p's> 1)

Conclusions For psychosocially functional patients, an RDH-lcd self-management regimen was equal or superior to dentist-delivered TMD care for reducing post-treatment TMD pain independent of TMD diagnosis This supports tailoring treatment to reflect level ofpsychosocial adaptation to chronic TMD pain

Acknowledgments Supported by NIH Grant DE10766


Ingnd Hurtig*. Ragnhild Raak*, Sally Aspcgrcn Kendall*. Birgitte Soren*, KG Hennksson, Lis Karm Wahren, Faculty of Health Sciences, L'niv of Linkoping, SE-581 85 Linkoping, Sweden

Aim To investigate whether thermal pain sensitivity differs be tween fibromyalgia patients and healthy pain-free subjects To develop a method to subgroup patients with fibromyalgia (FM) on the basis of psycho-physical responses to thermal pain

Method 29 fibromyalgia patients (1990 ACR Criteria) were invited to participate 21 pain-free healthy females served as controls Cold and heat pain thresholds were determined on the dorsum of the left hand, using a Thermotest instrument The current pain was scored on VAS Cold pain thresholds were established in the interval between skin temperature and +5C and heat pain thresholds between skm temperature and +52C

Results Both cold and heat pain thresholds differed significantly (p<0,0001) between FM patients and healthy subjects Pain at the testing site did not significantly influence the results The FM patients could be divided by cold pain threshold level into two group with +18C as a cut off point, cold pain normals (n=10) and cold pain sensitives (n= 19)

Conclusion Our results provide support for the hypothesis that the fibromyalgia syndrome is a heterogenous diagnosis group We show that it is possible to subgroup FM according to cold pain Thermal testing may prove a useful diagnostic tool


K Itoh*. K. Murase*, H Turu*, K Okada*, K Kawakita, Dept of Physiology, Meiji Univ of Oriental Medicine, Kyoto 629-0392, Japan

Aim of Investigation Clinical usefulness of trigger points (TrPs) treatment has become widely recognized, but their cause and process of development are poorly understood. The purpose of this study was to establish an expenmental model of the trigger point by loading eccentric exercise.

Methods: Seven healthy volunteers (aged 18-47 years) who gave informed consent were used An adjustable load was set around th< 3rd finger and the subject was asked to keep the position as long ai possible This loading (about 10 s) was repetitively continued until his all-out effort and it repeated 3 times with 5 mm resting periods Pressure pain thresholds (PPT- measured by palpometer) and deep pain thresholds (DPT measured at skin, fascia and muscle by puls' algometer, Unique Medical, Japan) were measured before, 2 and 7 days after the repetitive eccentnc exercise

Results: After the exercises the PPT was reduced at the restricted point on the extensor digital muscle where a taut band was palpated. Two days after the exercise, the PPTs were the lowest value and then increased gradually to the baseline level. Similar reduction of the DPT at the restricted point was observed only in the fascia. In several cases, volunteers often reported typical referred pain pattern during DPT measured at localized hyperalgesic point.

Conclusions: The present procedures produced localized hyperalgesic points on the palpable taut band and typical referred pain pattern was provoked by the stimulation of the points. These results suggest that this localized points are useful model of the trigger points, and sensitized nociceptors in the fascia might be a possible cause of the experimental trigger point model.


Mona Johansen. Thomas Graven-Nielsen, Anders Schou-Olesen, Lars Arendt-Nielsen. The Dep. of Rheumatology and the Pain Clinic, Aalborg Hospital. Center for Sensory-Motor Interaction, Laboratory for Experimental Pain Research, Aalborg Univ, Denmark.

Aim of Investigation: To investigate the somato-sensory sensibility and the central mechanism of referred pain in chronic whiplash patients and controls.

Methods: Eleven chronic whiplash patients and 11 controls were examined. The somato-sensory sensibility in the areas over the infraspinatus, brachioradial and anterior tibial muscles was assessed by pressure, pin-prick and cotton swap stimulation. Intramuscular infusion ofhypertonic saline (5.85%, 0.5ml) into the infraspinatus and anterior tibial muscles was performed to assess the muscular sensibility and referred pain patterns. The saline-induced muscle pain intensity was recorded on a VAS scale. The pain distributor patterns were drawn on an anatomical map.

Results: The pressure pain thresholds were significantly lower in the patient group in all 3 areas. There was no difference in the skin sensibility to pin-prick and cotton swap stimulation. Intramuscular infusion ofhypertonic saline caused significantly higher VAS scores with longer duration in patients compared to controls. The area under the VAS-time curve was significantly (P<0.01) increased in patients compared to controls after injection into the infraspinatus muscle (mean 4138 vs. 780 cm sec) and anterior tibial muscle (4371 vs. 979 cm sec). The areas of local and referred pain were significantly larger in patients, and both proximal and distal referred pain was seen.

Conclusion: In this study muscular hyperalgesia and larger referred pain areas were found in patients suffering from chronic whiplash syndrome compared to controls both within and outside the area where the patients experience pain. The findings suggest a generalised hyperexcitability in the patients.


Masaki Kitahara". Keiko Yamanouchi'1, Kunihiko Nagao1'*, Yukiko Yoshimoto5*, Akito Ohmura", Dept ofAnesthesiology" and Physical medicine and Rehabilitation1', Teikyo Univ Hospital Mizono-kuchi, Kawasaki, Kanagawa, 213-8507 JAPAN

Aim of Investigation: To investigate the importance ofmyofascial pain in patients who have retractable cancer pain.

Methods: A retrospective chart review of cancer patients who were referred to our clinical pain service because of their retractable pain was performed. Sites and nature of the pain, results of physical examinations, types of medical interventions administered to relieve the pain, and efficacy of those interventions were investigated.

Results: 56 patients (32 males and 24 females) were referred to our service between July 1996 and June 1998. 35 (20 males and 15 females) of them (62.5%) appeared to have myofascial component as an important cause of their pain. Low back pain and flank pain was most commonly caused by the myofascial pain. Trigger point injections were effective in 24 out of 28 patients (85.7%) at their initial evaluation. Administered treatments included trigger point injections (30 patients), physical therapy (29 patients), and tricyclic antidepressants (20 patients). 27 out of the 34 patients (79.4%) with the myofascial pain component showed significant relief of their initial pain within the first 30 days after the treatments were started.

Conclusions: The myofascial pain has been described as a factor of cancer pain. However no clinical investigation has ever been done. Our study revealed that the myofascial pain is an important factor of retractable cancer pain and that appropriate medical interventions can relieve the pain effectively and promptly.


S.Kusunoki *, K.Monwaki, K.Kawaguchi2 *, O.Yuge. Dept.of Anesthesiology and CCM, Inst of Health Sciences, School of Medicine, Hiroshima L'niv, Hiroshima, 734-8551, Japan

Aim of Investigation: To determine the existence of latent myofascial trigger points in the paravertebral muscles in patients with chronic pain states, and to define the relationship between these trigger points and sensory abnormalities or spontaneous pain.

Methods: Myofascial trigger points and tactile sensory abnormalities were studied in 313 patients with long-standing pain. The sites of any trigger points on tender paravertebral muscles, as well as areas ofhypoaesthesia, allodynia and spontaneous pain were recorded. The effects of trigger point inJection(s) on the ongoing pain were also evaluated by comparing pain scale scores before and after treatment.

Results: In 18 patients, latent myofascial trigger points existed in the paravertebral muscles. These shared the same spinal nerve supply as the painful area or region showing tactile sensory abnormalities. Injection of the trigger points in the paravertebral muscles relieved pain completely in two patients with primary myofascial pain. Moreover, the degree of pain was improved in five patients with post-thoracotomy pain syndrome, two with postherpetic neuralgia, two with cancer pain and five with other chronic painful conditions.

Conclusions: Latent trigger points for both primary and secondary myofascial pain appear to exist in paravertebral muscles innervated by the dorsal branches of spinal nerves, the anterior branches of which supply painful areas or areas showing tactile sensory abnormalities in patients with chronic pain states. The successful pain reduction achieved by injecting these points suggests that latent myofascial pain is at least partly responsible for aggravating and sustaining ongoing long-standing pain.

Acknowledgement: Supported in pan by the Second Term Comprehensive 10 Year Strategy for Cancer Control from the Japanese Ministry of Health and Welfare.


David R. Longmire. Univ of Alabama School ofMedicine-Huntsville Program, Huntsville AL USA; John Claude Krusz,Anodyne Paincare Center, Dallas TX USA

Aim of Investigation: To investigate clinical response to the ad-junctive treatment ofmyofascial pain with tizanidine hcl (Zanaf-lex) using Computer Assisted Drafting (CAD) analysis of PainDrawings.

Methods: Open label, prospective study of 30 adult patients withfibromyalgia or myofascial pain syndrome. Study treatment was provided as a low initial dose, ascending scale ( 0.25-8 mg po tid) of tizanidine hcl added to patients' current regimens. Patients were instructed to stop increasing the total Daily dose once significant relief was noted Outcome measures included verbal pain intensity (NRS11) for, and CAD area analysis of, each painful region on the Pain Drawings (PDs)

Results Twenty-eight of thirty patients described improvement during treatment Analysis ofpre-treatment PDs revealed 202 pain regions, the average pain intensity of which was 6 81 Dunng treatment this decreased to 124 regions with an average pain intensity of 5 23 The total area of all pain regions (pretreatment) was 139,773 sq mm and dunng treatment was 40,516 sq mm Conclusions Adjunct! ve use oftizanidine hcl (Zanaflex) reduced the average of all pain intensity scores by 23 2 %, and the total number of all pain regions by 38 6 % However, the greatest decrease in pain symptoms (71 0 %) was found in the total surface area of pain (pain extent) measured by computer analysis of pain drawings These results suggest that reduced pain area or extent may be a more sensitive measure of treatment benefit oftizanidine hcl than pain intensity

Acknowledgments Development of this analysis method was supported in part by an unrestricted educational grant from Elan Pharmaceuticals

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 43 - 49


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