CLINICAL ARTICLE REFERENCES FOR TOPICAL ANESTHETIC SKIN REFRIGERANTS
IMMUNIZATIONS:
K Abbott and S Fowler-Kerry
The use of a topical refrigerant anesthetic to reduce injection pain in children.
Journal of Pain and Symptom Management, November 1, 1995; 10(8): 584-90.
S Mawhorter, L Daugherty, A Ford, R Hughes, D Metzger, and K Easley
Topical vapocoolant quickly and effectively reduces vaccine-associated pain: results of a randomized, single-blinded, placebo-controlled study.
Journal of Travel Medicine, September 1, 2004; 11(5): 267-72.
E Cohen Reis and R Holubkov
Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children.
Pediatrics, December 1997; 100(6): E5.
VENIPUNCTURE:
P Armstrong, C Young and D McKeown
Ethyl chloride and venepunture pain: a comparison with intradermal lidocaine.
Canadian Journal of Anesthesia, Vol. 37, 656-658.
SJ Fetzer
Reducing the pain of venipuncture.
Journal of PeriAnesthesia Nursing, April 1999; Vol. 14, No. 2: 95-101
INTRAVENOUS CANNULATION:
K Farion, K Splinter, K Newhook, I Gaboury, W Splinter,
The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. Canadian Medical Association Journal, July 1, 2008; 179 (1).
CR Cannon and B Replogle
Fine-needle aspiration biopsy: is anesthesia necessary? Otolaryngology-Head and Neck Surgery, April 1999; 120(4): 458-9.
SC Russell and E Doyle
A risk-benefit assessment of topical percutaneous local anaesthetics in children.
Drug Safety, April 1997; 16(4): 279-87.
IR Selby and BJ Bowles
Analgesia for venous cannulation: a comparison of EMLA (5 minutes application), lignocaine, ethyl chloride and nothing.
Journal of the Royal Society of Medicine, May 1995; 88(5): 264-7.
SC Zappa and SB Nabors
Use of ethyl chloride topical anesthetic to reduce procedural pain in pediatric oncology patients.
Cancer Nursing, April 1, 1992; 15(2): 130-6.
MYOFASCIAL PAIN SYNDROME (MPS):
S Aftimos
Myofascial pain in children.
New Zealand Medical Journal, August 23, 1989; 102(874): 440-1.
D Alvarez and P Rockwell
Trigger Points: Diagnosis and Management.
American Family Physician, February 15, 2002; 65(4): 653-60.
P Barton
Piriformis syndrome: a rational approach to management.
Pain, December 1991; 47(3):345-52.
G Clark, D Seligman, W Solbert, and A Pullinger
Guidelines for the treatment of temporomandibular disorders.
Journal of Craniomandibular Disorders: Facial & Oral Pain, Spring 1990; 4(2): 80-8.
J Fricton
Clinical care for myofascial pain
Dental Clinics of North America, January 1991; 35(1): 1-28.
T Garvey, M Marks, and S Wiesel
A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain.
Spine, September 1989; 14(9): 962-4.
LR Halkovich, W Personius, H Clamann, and R Newton
Effect of Fluori-Methane spray on passive hip flexion.
Physical Therapy, February 1981; 61(2): 185-9.
SC Han, and P Harrison
Myofascial pain syndrome and trigger-point management
Regional Anesthesia, January-February; 22(1): 89-101.
RN Harden, SP Bruehl, S Gass, C Niemiec, and B Barbick
Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers.
The Clinical Journal of Pain, March 2000; 16(1): 64-72.
C Hou, L Tsai, K Cheng, K Chung, and C Hong
Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity.
Archives of Physical Medicine and Rehabilitation, October 2002; 83(10): 1406-14.
J Konzelman, W Herman, and R Corner
Pseudo-dental pain and sensitivity to percussion.
General Dentistry, March-April 2001; 49(2): 156-8.
LM Mandel, and SJ Berlin
Myofascial pain syndromes and their effect on the lower extremities.
The Journal of Foot Surgery, Spring 1982; 21(1): 74-9.
RR McClaflin
Myofascial pain syndrome – primary care strategies for early intervention.
Postgraduate Medicine, August 1994; 96(2): 56-9, 63-64, 66, 69-73.
D Rubin
Myofascial trigger point syndromes: an approach to management.
Archives of Physical Medicine and Rehabilitation, March 1981; 62(3): 107-10.
DG Simons, and JG Travell
Myofascial origins of low back pain. 1. Principles of diagnosis and treatment.
Postgraduate Medicine, February 1983; 73(2): 66, 68-70, 73.
W Teachey
Otolaryngic myofascial pain syndromes.
Current Pain and Headache Reports, December 2004; 8(6): 457-62.
JG Travell
Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia.
The Archives of Physical Medicine and Rehabilitation, March 1981; 62(3): 100-6.
MYOFASCIAL DYSFUNCTION OF THE HEAD AND NECK (TMD, TMJ):
D Alvarez, and P Rockwell
Trigger Points: Diagnosis and Management.American Family Physician, February 15, 2002; 65(4):653-60.
G Clark, D Seligman, W Solbert, and A Pullinger
Guidelines for the treatment of temporomandibular disorders.
Journal of Craniomandibular Disorders: Facial & Oral Pain, Spring 1990; 4(2): 80-8.
J Fricton
Clinical care for myofascial pain
Dental Clinics of North America, January 1991; 35(1): 1-28.
J Konzelman, W Herman, and R Corner
Pseudo-dental pain and sensitivity to percussion.
General Dentistry, March-April 2001; 49(2): 156-8.
D Rubin
Myofascial trigger point syndromes: an approach to management.
Archives of Physical Medicine and Rehabilitation, March 1981; 62(3): 107-10.
W Teachey
Otolaryngic myofascial pain syndromes.
Current Pain and Headache Reports, December 2004; 8(6): 457-62.
MEDLINE ABSTRACT
J Pain Symptom Manage, November 1, 1995; 10(8): 584-90.
The use of a topical refrigerant anesthetic to reduce injection pain in children.
Abbott K, Fowler-Kerry S.
Department of Medicine, Foothills Hospital, Calgary, Alberta, Canada.
Early childhood experiences with painful injections may lead to anxiety and fear. These reactions need not develop if steps are taken to reduce the pain associated with injections. The purpose of this study was to assess the efficacy of a refrigerant topical anesthetic in reducing injection pain in preschool children experiencing routine diphtheria-pertussis-tetanus (DPT) immunizations. This double-blind placebo-controlled study was conducted in community health clinics in conjunction with ongoing immunization programs. Ninety subjects, aged 4-5.5 years, were randomly assigned to one of three groups: (a) refrigerant topical anesthetic; (b) placebo topical spray; and (c) no-spray control. Pain was measured subjectively using a four-point visual analogue scale. Both the refrigerant topical anesthetic spray and the placebo spray significantly reduced injection pain. Age was found to be an important factor influencing pain response in this study. Parental anxiety was not a significant factor influencing pain response. In addition, parents were not good at predicting their child's pain. The results of the study support the use of an intervention, such as refrigerant topical anesthetic, as a practical, simple, and effective treatment strategy for reduction of short-term painful procedures like injections.
MEDLINE ABSTRACT
Can J Anaesth. 1990 Sep;37(6):656-8.
Ethyl chloride and venepuncture pain: a comparison with intradermal lidocaine.
Armstrong P, Young C, McKeown D.
Department of Anaesthesia, Royal Infirmary of Edinburgh, Scotland.
One hundred and twenty unpremedicated patients undergoing gynaecological surgery were randomly allocated to one of three equal treatment groups to assess the effectiveness of ethyl chloride in producing instant skin anaesthesia to prevent the pain of venepuncture from a 20 G cannula. They received either no anaesthetic, 0.2 ml one per cent lidocaine plain intradermally or a ten-second spray of ethyl chloride at the cannulation site. Ethyl chloride produced skin anaesthesia that significantly reduced the pain of venepuncture. However, it was not as effective as intradermal lidocaine. It had no effect on vein visualisation or ease of cannulation. Ethyl chloride can be recommended as a method of producing instant skin anaesthesia.
MEDLINE ABSTRACT
Otolaryngol Head Neck Surg. 1999 Apr;120(4):458-9.
Fine-needle aspiration biopsy: is anesthesia necessary?
Cannon CR, Replogle B.
Department of Surgery, University Medical Center, Jackson, MS, USA.
Fine-needle aspiration (FNA) of inflammatory and neoplastic head and neck masses has become a widely used procedure in otolaryngology-head and neck surgery. Using both subjective (patient perception) and objective (complication rate, accuracy) criteria, this prospective study evaluated patients undergoing FNA with and without anesthesia. Seventy-five patients were enrolled into 1 of 3 study groups: group I, no anesthesia; group II, ethyl chloride spray; and group III, lidocaine infiltrative anesthesia. In general, the ease of FNA, complication rates, and accuracy rates were the same for the 3 groups. Patient perception and satisfaction rates were improved in groups II and III. Use of topical or infiltrative anesthesia may enhance the use of FNA in the anxious nervous patient undergoing FNA of a neck mass.
MEDLINE ABSTRACT
J Perianesth Nurs. 1999 Apr;14(2):95-101, 112
Reducing the pain of venipuncture.
Fetzer SJ.
University of New Hampshire, Keene, USA.
Patient satisfaction with nursing care is the strongest predictor of overall satisfaction.Reducing discomfort of routine procedures, such as venipuncture for an intravenous insertion, can contribute to perceived satisfaction. This article reviews three common pharmacological interventions that can be used by perianesthesia nurses to reduce the pain of venipuncture.
MEDLINE ABSTRACT
CMAJ. 2008 July 1; 179(1): 31–36. doi: 10.1503/cmaj.070874PMCID: PMC3267474
The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial
Ken J. Farion, MD, Karen L. Splinter, MD, Kym Newhook, BScN RN, Isabelle Gaboury, MSc, and William M. Splinter, MD
From the Departments of Pediatrics (Farion), Emergency Medicine (Farion) and Anesthesiology (K.L. Splinter, W.M. Splinter), University of Ottawa; the Emergency Department (Newhook), Children's Hospital of Eastern Ontario; and the Children's Hospital of Eastern Ontario Research Institute (Gaboury), Ottawa, Ont
Established noninvasive pharmacologic means of alleviating pain and anxiety in children undergoing intravenous cannulation are time-consuming, and thus impractical for routine use in the emergency department. Vapocoolant sprays provide transient skin anesthesia within seconds of application. We compared the effect of a new vapocoolant spray to placebo on pain due to intravenous cannulation in children. In this double-blind randomized controlled trial, which we conducted between June 1 and Sept. 12, 2006, 80 children aged 6–12 years received either vapocoolant spray or placebo before cannulation. Children rated their pain using a 100-mm colour visual analogue scale. Secondary outcomes included success rate on first attempt at cannulation and pain ratings by the children's parents, nurses and child life specialists. We found a modest but significant reduction in pain with the use of vapocoolant spray (mean difference 19 mm, 95% confidence interval [CI] 6–32 mm; p < 0.01). Cannulation on first attempt was more often successful with the use of vapocoolant spray (85.0%) than with placebo (62.5%) (mean difference 22.5%, 95% CI 3.2%–39.9%; p = 0.03). The number needed to treat to prevent 1 cannulation failure was 5 (95% CI 3–32). Parents (p = 0.04), nurses (p = 0.01) and child life specialists (p < 0.01) considered the children's pain to be reduced with the use of vapocoolant spray. The vapocoolant spray in our study quickly and effectively reduced pain due to intravenous cannulation in children and improved the success rate of cannulation. It is an important option to reduce childhood procedural pain in emergency situations, especially when time precludes traditional interventions.
MEDLINE ABSTRACT
J Travel Med. 2004 Sep-Oct;11(5):267-72.
Topical vapocoolant quickly and effectively reduces vaccine-associated pain:
results of a randomized, single-blinded, placebo-controlled study.
Mawhorter S, Daugherty L, Ford A, Hughes R, Metzger D, Easley K.
Department of Infectious Disease, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
BACKGROUND: Comprehensive international travel preparation often requires several vaccines. Up to 90% of adults have some fear of injections, mostly due to injection-related pain. Pediatric studies with routine vaccines have shown topical anesthetic EMLA cream (lidocaine and prilocaine, Astra Pharmaceuticals, Inc.) and the topical vapocoolant Fluori-Methane (dichlorodifluoromethane and trichlorodifluoromethane, Gebauer Co.) to be equally effective in reducing pain from vaccinations. EMLA cream is expensive and requires a 60-min application, while Fluori-Methane (FM) is immediate in onset of action and inexpensive. Skin anesthesia begins at 10 degrees C. Fluori-Methane can briefly cool the skin to 0 degrees C. METHODS: We studied the effectiveness of topical vapocoolant on adult clients at our international travel clinic in a randomized, controlled trial of topical FM vs. cold (4 degrees C) saline placebo. Using a preset randomization table, participants served as their own controls, receiving placebo/control or active agent (participant blinded) in one arm (left or right), and a similar number of vaccines in the untreated arm. Vaccines were administered according to a set protocol per arm to minimize the risk of bias. Pain was measured using a modified McGill present pain intensity (PPI) pain index. Subjects rated their pain immediately and at 5 min on a six-level scale, noting treated and untreated arms separately. A questionnaire was completed on intervention preferences. Sample size was predetermined to achieve 90% statistical power estimating 25% efficacy (minimum n=172). RESULTS: One hundred and eighty-five participants were enrolled; 93 FM and 92 cold saline placebo. FM-treated arms had a significant reduction in immediate pain compared to untreated arms (pain scale mean 2.2 vs. 3.1; p<.0001), and compared to placebo (mean 2.2 vs. 2.8; p<.01). Delayed pain at 5 min was not affected by FM or control (mean 1.9 vs. 2.0) compared to no intervention (pain scale 1.9). The intervention preference questionnaire indicated that participants did not find FM therapy uncomfortable. They would choose FM therapy in the future, over a cream, especially if a wait was involved. CONCLUSION: The topical vapocoolant Fluori-Methane is an effective, quick, preferred, inexpensive agent for reducing vaccine-associated injection pain for international travel clients.
MEDLINE ABSTRACT
Pediatrics. 1997 Dec;100(6):E5.
Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children.
Cohen Reis E, Holubkov R.
Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
BACKGROUND: Untreated immunization pain causes undue distress and contributes to underimmunization through physician, and possibly parental, resistance to multiple simultaneous injections. OBJECTIVE: To compare the efficacies of two pain management methods in reducing immediate immunization injection pain and distress in school-aged children. DESIGN: A randomized, controlled clinical trial of eutectic mixture of local anesthetics (EMLA) cream and vapocoolant spray. PATIENTS: Children aged 4 to 6 years and scheduled to receive diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) during health supervision visits. INTERVENTIONS: Enrolled children were randomized to one of three treatment groups: 1) EMLA cream + distraction; 2) vapocoolant spray + distraction; or 3) distraction alone (control). The specific pharmacologic pain control interventions consisted of EMLA cream (2.5% lidocaine, 2.5% prilocaine [Astra Pharmaceutical Products, Inc, Westborough, MA] $15. 00/patient; applied 60 minutes before injection) and vapocoolant spray (Fluori-Methane [Gebauer Company, Cleveland, OH] $0. 50/patient; applied via spray-saturated cotton ball for 15 seconds immediately before injection). MAIN OUTCOME MEASURES: The blinded investigator (BI) measured (by edited videotape) cry duration and the number of pain behaviors using the Observational Scale of Behavioral Distress. Pain visual analog scales (linear and faces scales) were completed by the child, parent, nurse, and the BI. RESULTS: Sixty-two children, aged 4.5 +/- 0.4 years (mean +/- SD) were randomized. The three treatment groups had similar subject characteristics. All pain measures and cry duration were similar for EMLA and vapocoolant spray. Both EMLA and spray were significantly better than control. Results for spray vs control: cry duration (seconds): 8.5 +/- 21.0 vs 38.6 +/- 50.5; number of pain behaviors: 1.2 +/- 1.9 vs. 3.1 +/- 2.1; child-scored faces scale: 2.0 +/- 2.4 vs. 4.1 +/- 2.3; parent-scored faces scale: 1.6 +/- 1.6 vs. 3.0 +/- 1.7; nurse-scored faces scale: 1.6 +/- 1.2 vs. 3.1 +/- 1.4; and BI-scored faces scale: 1.0 +/- 1.5 vs. 2.4 +/- 1.4. CONCLUSIONS: When combined with distraction, vapocoolant spray significantly reduces immediate injection pain compared with distraction alone, and is equally effective as, less expensive, and faster-acting than EMLA cream. As an effective, inexpensive, and convenient pain control method, vapocoolant spray may help overcome physician and parent resistance to multiple injections that leads to missed opportunities to immunize.
MEDLINE ABSTRACT
Drug Saf. 1997 Apr;16(4):279-87.
A risk-benefit assessment of topical percutaneous local anaesthetics in children.
Russell SC, Doyle E.
Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh, Scotland.
Since its introduction, eutectic lidocaine-prilocaine cream ('EMLA')1 has been found to be an effective topical anaesthetic agent, with a high degree of efficacy, particularly for venepuncture and venous cannulation, and an impressive tolerability profile. Reports of adverse effects are remarkable for their rarity. The only problems that are likely to be encountered are oral ingestion of the cream (which may lead to anaesthesia of the oropharynx and possible toxicity secondary to rapid absorption of local anaesthetic from oral mucous membranes) and methaemoglobinaemia following repeated applications in neonates and infants. Analysis of the risks and benefits associated with its use comes down heavily in favour of the preparation. More recently, a preparation of tetracaine (amethocaine) has been marketed as a gel. Its advantages are a faster onset, and longer duration, of action than 'EMLA'. Although less widely used, it too has an impressive tolerability record. Concerns over the potential for anaphylactic type reactions due to its ester structure have not been realised in clinical practice. Of the other available preparations, lidocaine (lignocaine), applied iontophoretically, is unlikely to become popular because of the complexity of administration. A paste made of tetracaine, epinephrine (adrenaline) and cocaine (TAC) appears to be a far more toxic preparation on theoretical grounds, and this has been borne out in clinical practice; it is not as well tolerated as 'EMLA' or tetracaine gel. Ethyl chloride, although not a local anaesthetic, can safely provide cutaneous analgesia in children in circumstances when it is impractical to wait for a local anaesthetic preparation to take effect.
MEDLINE ABSTRACT
R Soc Med. 1995 May;88(5):264-7
Analgesia for venous cannulation: a comparison of EMLA (5 minutes application), lignocaine, ethyl chloride, and nothing.
Selby IR, Bowles BJ.
Anaesthetic Department, Hope Hospital, Lancashire, UK.
Three commonly available local anaesthetics were compared, in a controlled trial, for use before venous cannulation. The pain of application of the local anaesthetic, the pain of cannulation, and the rate of successful cannulations were compared. The value of EMLA cream applied for 5 min was questioned. Venous cannulation with a 20G venflon was found to be significantly more painful than the application of any of the local anaesthetics (P < 0.01). Lignocaine 1%, injected subcutaneously, and ethyl chloride spray significantly reduced the pain of venous cannulation (P < 0.01). The use of lignocaine did not result in significantly more failed cannulations than the control group. It was concluded that local anaesthesia should be used before venous cannulation, even for 20G cannulae.
MEDLINE ABSTRACT
Cancer Nurs. 1992 Apr;15(2):130-6.
Use of ethyl chloride topical anesthetic to reduce procedural pain in pediatric oncology patients.
Zappa SC, Nabors SB.
Hematology-Oncology Outpatient Department, Cook-Fort Worth Children's Medical Center, Texas 76104.
Pediatric cancer patients often become anxious, agitated, combative, and uncooperative due to the pain or fear of pain during invasive procedures. Generally, it is not the actual administration of medicines that produces this reaction, but the fear of the needle stick itself. Increased education and implementation of coping mechanisms is often not enough to allay this fear. The tangible solution of using ethyl chloride, an anesthetic spray, before port sticks, lumbar punctures, and bone marrow aspirations, was instituted by the hematology-oncology clinic to determine if the pain, emotional trauma, and fear of cancer treatments could be reduced in oncology patients. Survey results on 60 patients and 60 parents/caretakers showed that when given the choice to use the spray or to refuse its use, 68% of the parents thought that the patient had more of a sense of control and, thus, involvement in their treatment. Seventy-eight percent of the patients reported experiencing less pain associated with procedures. Staff noted an increase in cooperation, less combativeness, and more compliance with treatment. Perceiving the child's discomfort diminished, 87% of the parents/caretakers report feeling less anxious and, therefore, more capable of being supportive to each other and their child. These results verified the staff's perceptions of the advantages of using this noninvasive anesthetic. Ethyl chloride is an easy, effective, concrete approach to reducing procedural pain in pediatric oncology patients.
MEDLINE ABSTRACT
N Z Med J. 1989 Aug 23;102(874):440-1.
Myofascial pain in children.
Aftimos S.
Mary Hospital, Auckland.
Five children with acute and chronic regional myofascial pain syndromes, involving the sternomastoid, the external oblique, the rectus abdominis and the biceps femoris, are described. The trigger points were treated initially by vapocoolant therapy followed by muscle stretching, and subsequently by moist heat applications and continuing muscle stretching. The pain resolved in all cases. Such syndromes received little attention in the medical literature, and consequently, affected patients have been given alternative diagnoses. The article seeks better recognition of such syndromes in order to provide adequate and appropriate management.
MEDLINE ABSTRACT
Am Fam Physician. 2002 Feb 15;65(4):653-60.
Trigger points: diagnosis and management.
Alvarez DJ, Rockwell PG.
Department of Family Medicine, University of Michigan Medical School, Ann Arbor, USA. dalvarez@umich.edu
Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms.
MEDLINE ABSTRACT
Pain. 1991 Dec;47(3):345-52.
Piriformis syndrome: a rational approach to management.
Barton PM.
Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Canada.
Although rarely recognized, the piriformis syndrome appears to be a common cause of buttock and leg pain as a result of injury to the piriformis muscle. Four cases representing a broad spectrum of presentations are described here. The major findings include buttock tenderness extending from the sacrum to the greater trochanter and piriformis tenderness on rectal or pelvic examination. Symptoms are aggravated by prolonged hip flexion, adduction, and internal rotation, in the absence of low back or hip findings. Minor findings may include leg length discrepancy, weak hip abductors, and pain on resisted hip abduction in the sitting position. Myofascial involvement of related muscles and lumbar facet syndromes may occur concurrently. The diagnosis is primarily clinical as no investigations have proved definitive. The role of MRI of the piriformis muscle is assessed and other investigative tools are discussed. A rational management schema is demonstrated: (1) underlying biomechanical factors and associated conditions should be corrected; (2) the patient is instructed in a home program of prolonged piriformis muscle stretching which may be augmented in physical therapy by preceding ultrasound or Fluori-Methane (dichlorodifluoromethane and trichloromonofluoromethane spray); (3) a trial of up to three steroid injections is attempted; and (4) if all these measures fail, consideration should be given to surgical sciatic nerve exploration and piriformis release.
MEDLINE ABSTRACT
J Craniomandib Disord. 1990 Spring;4(2):80-8.
Guidelines for the treatment of temporomandibular disorders.
Clark GT, Seligman DA, Solberg WK, Pullinger AG.
Dental Research Institute, University of California, Los Angeles, School of Dentistry 90024.
These guidelines include the usual and customary treatment approaches recommended for each of the diagnostic categories described in a previous article on the examination and diagnosis of temporomandibular disorders. The current article describes when it is appropriate to use initial therapy, behavior modification therapy, pharmacotherapy, occlusal appliances, physical therapy, and surgical treatment for temporomandibular disorders. The physical therapy procedures described include various exercises as well as pain-relief techniques such as vapocoolant spray, massage, electrical stimulation of muscles and nerves, ultrasound, and trigger-point injections. Pharmacotherapy using muscle relaxant, nonsteroidal anti-inflammatory, tricyclic antidepressant, and narcotic pain medications are also discussed. Occlusal stabilization and repositioning appliances are reviewed as well. Finally, the broad indications for arthroscopic surgery, open surgery, and steroid injections are described.
MEDLINE ABSTRACT
Dent Clin North Am. 1991 Jan;35(1):1-28.
Clinical care for myofascial pain.
Fricton JR.
Department of Diagnostic and Surgical Sciences, School of Dentistry, University of Minnesota, Minneapolis.
Myofascial pain (MFP) is a regional muscle pain disorder characterized by localized tenderness in taut muscle bands and referred pain. Frequently, MFP is overlooked as a common cause of chronic pain because of the frequent association with joint dysfunction and other pain disorders and the multiple behavioral and psychosocial contributing factors that are often present. Nonetheless, studies have reported that MFP is present in a significant number of people. This article describes current concepts for the diagnosis and management of MFP.
MEDLINE ABSTRACT
Spine. 1989 Sep;14(9):962-4.
A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain.
Garvey TA, Marks MR, Wiesel SW.
Department of Orthopaedic Surgery, George Washington University Medical Center, Washington, D.C.
The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. 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.
MEDLINE ABSTRACT
Phys Ther. 1981 Feb;61(2):185-9.
Effect of Fluori-Methane spray on passive hip flexion.
Halkovich LR, Personius WJ, Clamann HP, Newton RA.
The purpose of the study was to evaluate the influence of Fluori-Methane spray as a method of affecting passive range of motion measured at the right hip joint. Subjects were 30 normal volunteers randomly divided into an experimental group and a control group. A special table was constructed to position and stabilize each subject for monitoring the right lower extremity's resistance to side-lying straight leg raising. Specific right hip flexion goniometric measurements were compared and analyzed before and after application of Fluori-Methane spray to the soft tissue overlying the posterior part of the right thigh. The results of the study showed that the experimental group, which received application of Fluori-Methane spray and static passive stretch, did significantly (p less than .02) increase the range of passive hip flexion over that of the control group, which received only static passive stretch.
MEDLINE ABSTRACT
Reg Anesth. 1997 Jan-Feb;22(1):89-101.
Myofascial pain syndrome and trigger-point management.
Han SC, Harrison P.
Department of Anesthesiology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
BACKGROUND AND OBJECTIVES: Myofascial pain syndrome (MPS) is a common condition often resulting in referral to a pain clinic. The epidemiology, pathogenesis, and various diagnostic tools are reviewed, and a variety of treatment methods are discussed. METHODS: Extensive periodical literature and textbooks are reviewed, and selected manuscripts are critically analyzed. RESULTS: The incidence of MPS with associated trigger points appears to vary between 30 and 85% of people presenting to pain clinics, and the condition is more prevalent in women than in men. Patients complain of regional persistent pain, ranging in intensity and most frequently found in the head, neck, shoulders, extremities, and low back. Muscle histologic abnormalities have been described in some studies. Similarly, electromyographic, thermographic, and pressure algometric studies have inconsistently identified abnormalities. 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. CONCLUSIONS: The definitive pathogenesis of MPS is currently unknown, and no single diagnostic method is consistently positive. While trigger-point injection is the most widely employed method of treatment, other modes of therapy have also proved to be effective.
MEDLINE ABSTRACT
Clin J Pain. 2000 Mar;16(1):64-72.
Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers.
Harden RN, Bruehl SP, Gass S, Niemiec C, Barbick B.
Center for Pain Studies, Rehabilitation Institute of Chicago, Illinois 60611, USA. nharden@rehabchicago.org
OBJECTIVE: The goal of this study was to assess clinical consensus regarding whether myofascial pain syndrome (MPS) is a legitimate and distinct diagnosis as well as the signs and symptoms characterizing MPS. DESIGN: A standardized mailed survey with return postage provided. SUBJECTS: A total of 1,663 American Pain Society members in medically related disciplines listed in the 1996/1997 directory. OUTCOME MEASURES: A standardized survey assessing clinical opinion regarding whether MPS is a legitimate diagnosis, whether MPS is a clinical entity distinct from fibromyalgia, and the signs and symptoms believed to be "essential to," "associated with," or "irrelevant to" to the diagnosis of MPS. RESULTS: Of the 403 surveys returned, 88.5% respondents reported that MPS was a legitimate diagnosis, with 81% describing MPS as distinct from fibromyalgia. The only signs and symptoms described as essential to the diagnosis of MPS by greater than 50% of the sample were regional location, presence of trigger points, and a normal neurologic examination. Regarding the signs and symptoms considered to be essential or associated with MPS, more than 80% of respondents agreed on regional location, trigger points, normal neurologic examination, reduced pain with local anesthetic or "spray and stretch," taut bands, tender points, palpable nodules, muscle ropiness, decreased range of motion, pain exacerbated by stress, and regional pain described as "dull," "achy," or "deep." Sensory or reflex abnormalities, scar tissue, and most test results were considered to be irrelevant to the diagnosis of MPS by a large proportion of the respondents. CONCLUSIONS: There was general agreement across specialties that MPS is a legitimate diagnosis distinct from fibromyalgia. There was a high level of agreement regarding the signs and symptoms essential or associated with a diagnosis of MPS. Differences across specialties are discussed. This survey provides a first step toward the development of consensus-based diagnostic criteria for MPS, which can then be validated empirically.
MEDLINE ABSTRACT
Arch Phys Med Rehabil. 2002 Oct;83(10):1406-14.
Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity.
Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ.
Institute of Biomedical Engineering, National Cheng Kung University, Taina, Taiwan. hcr@speech114.csie.ncku.edu.tw
OBJECTIVE: To investigate the immediate effect of physical therapeutic modalities on myofascial pain in the upper trapezius muscle. DESIGN: Randomized controlled trial. SETTING: Institutional practice. PATIENTS: One hundred nineteen subjects with palpably active myofascial trigger points (MTrPs). INTERVENTION: Stage 1 evaluated the immediate effect of ischemic compression, including 2 treatment pressures (P1, pain threshold; P2, averaged pain threshold and tolerance) and 3 durations (T1, 30s; T2, 60s; T3, 90s). Stage 2 evaluated 6 therapeutics combinations, including groups B1 (hot pack plus active range of motion [ROM]), B2 (B1 plus ischemic compression), B3 (B2 plus transcutaneous electric nerve stimulation [TENS]), B4 (B1 plus stretch with spray), B5 (B4 plus TENS), and B6 (B1 plus interferential current and myofascial release). MAIN OUTCOME MEASURES: The indexes of changes in pain threshold (IThC), pain tolerance (IToC), visual analog scale (IVC), and ROM (IRC) were evaluated for treatment effect. RESULTS: In stage 1, the IThC, IToC, IVC, and IRC were significantly improved in the groups P1T3, P2T2, and P2T3 compared with the P1T1 and P1T2 treatments (P<.05). In stage 2, groups B3, B5, and B6 showed significant improvement in IThC, ItoC, and IVC compared with the B1 group; groups B4, B5, and B6 showed significant improvement in IRC compared with group B1 (P<.05). CONCLUSIONS: Ischemic compression therapy provides alternative treatments using either low pressure (pain threshold) and a long duration (90s) or high pressure (the average of pain threshold and pain tolerance) and short duration (30s) for immediate pain relief and MTrP sensitivity suppression. 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 easing MTrP pain and increasing cervical ROM. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
MEDLINE ABSTRACT
Gen Dent. 2001 Mar-Apr;49(2):156-8.
Pseudo-dental pain and sensitivity to percussion.
Konzelman JL Jr, Herman WW, Comer RW.
Department of Oral Diagnosis and Patient Services, School of Dentistry, Medical College of Georgia.
Two case reports examine a little-known cause of dental pain and sensitivity to percussion. Contrary to the traditional assumption that pain and sensitivity to percussion almost always are diagnostic of pulpal inflammation and/or necrosis, these symptoms actually may be referred to the sensitive tooth from trigger points in the masticatory muscles. Therefore, myofascial pain syndrome must be ruled out in patients who have dental pain and display sensitivity to percussion.
MEDLINE ABSTRACT
J Foot Surg. 1982 Spring;21(1):74-9.
Myofascial pain syndromes and their effect on the lower extremities.
Mandel LM, Berlin SJ.
Podiatric Section, University of Missouri, School of Medicine, Kansas City, Missouri.
Myofascial pain syndrome is an entity with which every podiatrist should be familiar. These disorders are usually the result of acute or chronic injury and are characterized by the presence of trigger areas and symptom complexes that have definite patterns. Once these patterns have been learned, the sources of pain can be readily predicted. Most of these conditions can be effectively treated in the podiatrist's office by local block techniques and/Or by application of Fluori-Methane spray. It is important to consult the appropriate medical specialist for diagnostic confirmation or for aid in treatment if uncertainty exists. Treatment regimens in this group of syndromes are based on the notion that in these disorders there is a self-sustaining cycle of pain-spasm-pain persisting after the precipitating cause has disappeared, which may be permanently abolished by interruption of the reflex mechanisms. In order to produce optimal results, the trigger area must be accurately located and treatment directed toward its elimination. Physical therapy and active exercise are necessary adjuncts to local blocks. Not all patients respond, and in many the response is slow, incomplete, and/or only temporary, but there are those in whom these simple measures provide relief of pain and disability in a manner as dramatic as one is likely to encounter in practice.
MEDLINE ABSTRACT
Postgrad Med. 1994 Aug;96(2):56-9, 63-6, 69-70 passim.
Myofascial pain syndrome. Primary care strategies for early intervention.
McClaflin RR.
Department of Family Medicine, Sioux Falls Family Practice Residency, University of South Dakota School of Medicine.Diagnosis of myofascial pain syndrome may become less challenging as clinical criteria become better defined. The mechanisms are not well known, and the syndrome occurs in a wide variety of settings. Trigger points with referred pain are the most common feature. Treatment consists of physical modalities (spray-and-stretch techniques and trigger point block) combined with a program of graded muscle stretching and strengthening. Early, aggressive treatment yields an improved prognosis.
MEDLINE ABSTRACT
Arch Phys Med Rehabil. 1981 Mar;62(3):107-10.
Myofascial trigger point syndromes: an approach to management.
Rubin D.
Department of Physical Medicine and Rehabilitation, University of Southern California-Los Angeles County General Hospital, Los Angeles, California.The treatment of myofascial trigger point (TP) pain syndromes is not difficult once the source of the problem has been determined. Whereas many modalities may be used, two of the most effective are spray-and-stretch and TP injection. These can be followed by deep massage, specific, manual resistive exercises, and an exercise program which the patient can follow at home. The goal of management is to inactivate the TPs and to restore shortened and stretch resistant muscles to their full range of motion. A number of such syndromes are discussed in terms of recognition and management.
MEDLINE ABSTRACT
Postgrad Med. 1983 Feb;73(2):66, 68-70, 73 passim.
Myofascial origins of low back pain. 1. Principles of diagnosis and treatment.
Simons DG, Travell JG.
Myofascial trigger points (TPs) are frequently overlooked sources of acute and chronic low back pain. An active myofascial TP is suspected by its focal tenderness to palpation and by restricted stretch range of motion. The restricted lengthening of the muscle is due to the tense band of muscle fibers in which the TP is located. The presence of a TP is confirmed by a local twitch response and by reproduction of its known pattern of referred pain, which matches the distribution of the patient's pain. Only an active TP causes a clinical pain complaint; a latent TP does not. The pain can be relieved by the stretch-and-spray procedure, ischemic compression, or precise injection of the TP with procaine solution. Relief is usually long lasting only if mechanical and systemic perpetuating factors are corrected.
MEDLINE ABSTRACT
Curr Pain Headache Rep. 2004 Dec;8(6):457-62.
Otolaryngic myofascial pain syndromes.
Teachey WS.
Haygood Medical Center, 1020 Independence Blvd., Suite 313, Virginia Beach, VA 23455, USA.It has been long recognized in the otolaryngic community that despite great effort dedicated to the physiology and pathology of the ear, nose, throat/head and neck, there are a number of symptoms, including pain in various locations about the head and neck, which cannot be explained by traditional otolaryngic principles. The tenets of myofascial dysfunction, however, as elucidated by Dr. Janet Travell, explain most of these previously unexplained symptoms; furthermore, treatment based on Dr. Travell's teachings is effective in relieving these symptoms.
MEDLINE ABSTRACT
Arch Phys Med Rehabil. 1981 Mar;62(3):100-6.
Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia.
Travell J.
Myofascial trigger points (TPs) in a muscle are usually activated by acute or chronic overload of the muscle. They are identified by objective and subjective findings. Objective signs include a palpably firm, tense band in the muscle, production of a local twitch response, restricted stretch range-of-motion, weakness without atrophy, and no neurologic deficit. Subjectively, the patient reports stiffness and easy fatigability, spontaneous pain in a distribution predictable for that TP, an exquisite deep tenderness specifically at the TP. Sustained pressure on the TP induces referred pain in the predicted pattern. Some muscles are likely to produce additional objective and subjective autonomic concomitants. Laboratory and radiographic findings are negative. The affected muscle is treated by passive stretch while a jet stream of vapocoolant spray is applied over it, or by injection of the TP with a local anesthetic. A case report describes in detail the treatment of a patient who, for 13 years, had suffered from a medically enigmatic, intense right facial pain with severe dysfunction and who is now pain-free, with a full schedule of unrestricted activities 23 years later.