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Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain
Journal of Bodywork & Movement Therapies xxx (2017) 1e5
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Original research
Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain Almir Vieira Dibai-Filho, PT, PhD a, Rinaldo Roberto de Jesus Guirro, PT, PhD a, ^nia Tie Koga Ferreira, PT, PhD a, Alessandra Kelly de Oliveira, PT a, Va Ana Maria de Almeida, RN, PhD b, Elaine Caldeira de Oliveira Guirro, PT, PhD a, * a
Postgraduate Program in Rehabilitation and Functional Performance, Department of Biomechanics, Medicine, and Rehabilitation of the Locomotor ~o Preto, University of Sa ~o Paulo, Ribeira ~o Preto, SP, Brazil Apparatus, Medical School of Ribeira ~o Preto, University Postgraduate Program in Nursing in Public Health, Department of Maternal-Infant and Public Health Nursing, Nursing School of Ribeira ~o Paulo, Ribeira ~o Preto, SP, Brazil of Sa b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 January 2017 Received in revised form 20 April 2017 Accepted 25 April 2017
Myofascial trigger points are present in dysfunctioning muscles and are associated with several diseases. However, the scientific literature has not established whether myofascial trigger points of differing etiologies have the same clinical characteristics. Thus, the objective of the present study was to compare the intensity of myofascial pain, catastrophizing, and the pressure pain threshold at myofascial trigger points among breast cancer survivors and women with neck pain. This was a cross-sectional study that included women over 18 years old complaining of myofascial pain in the upper trapezius muscle region for more than 90 days, equally divided into breast cancer survivors (n ¼ 30) and those with neck pain (n ¼ 30). For inclusion, the presence of a bilateral, active, and centrally located trigger point with mean distance from C7 to acromion in the upper trapezius was mandatory. The measures of assessment were: pain intensity, catastrophizing, and the pressure pain threshold at the myofascial trigger points. A significant difference was observed only when comparing pain intensity (p < 0.001) between the breast cancer survivors (median score: 8.00 points, first quartile: 7.00 points, third quartile: 8.75 points) and women with neck pain (median score: 2.50 points, first quartile: 2.00 points, third quartile: 4.00 points). No significant difference was found between groups in catastrophizing and pressure pain threshold. The conclusion of this study was that breast cancer survivors have a higher intensity of myofascial pain in the upper trapezius muscle when compared to patients with neck pain, which indicates the need for evaluation and a specific intervention for the myofascial dysfunction of these women. © 2017 Published by Elsevier Ltd.
Keywords: Myofascial pain syndromes Muscle Skeletal Chronic pain
1. Introduction Myofascial trigger points are pathological structures present in skeletal muscles and are related to sensory, motor, and autonomic changes (Bron and Dommerholt, 2012). They are defined as palpable nodules located in the taut band of a muscle. They also produce local and referred pain and may be active or latent (Ge and Arendt-Nielsen, 2011; Bron and Dommerholt, 2012). Moreover, metabolic (Larsson et al., 2008), vascular (Larsson et al., 1999), and
~o Paulo, Faculdade de Medicina de * Corresponding author. Universidade de Sa ~o Preto, Pre dio da Fisioterapia e Terapia Ocupacional, Avenida dos BandeirRibeira ~o Preto CEP 14049-900, SP, Brazil. antes, 3900, Monte Alegre, Ribeira E-mail address: [email protected] (E.C. de Oliveira Guirro).
electromyographic changes (Zakharova-Luneva et al., 2012) can also be observed in these dysfunctioning tissues. In pathophysiological terms, it is hypothesised that there is a metabolic impairment in this clinical condition, because the increase in muscular activity produces an increase in intramuscular pressure with subsequent mechanical compression of the blood vessels in the muscle; because of this, a series of cascading events are thought to occur, such as a reduction in the supply of oxygen and glucose, ineffective aerobic metabolism, activation of anaerobic metabolism for the formation of adenosine triphosphate, the buildup of lactic acid, a reduction in intramuscular hydrogenionic potential, a reduction in acetylcholinesterase activity and increased acetylcholine action, an increase in the concentration of intracellular calcium, stronger interactions between actin and myosin,
http://dx.doi.org/10.1016/j.jbmt.2017.04.012 1360-8592/© 2017 Published by Elsevier Ltd.
Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012
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A.V. Dibai-Filho et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e5
inflammation, and muscle damage (Bron and Dommerholt, 2012; Moraska et al., 2013). Myofascial trigger points are present in dysfunctioning muscles and are associated with several, conditions such as temporomanndez-de-Las-Pen ~ as et al., 2010), lower back dibular disorder (Ferna pain (Iglesias-Gonz alez et al., 2013), shoulder impingement syndrome (Delgado-Gil et al., 2015), and migraine (Tali et al., 2014), even affecting individuals with neck pain (Dibai-Filho et al., 2015) and breast cancer survivors (Cantarero-Villanueva et al., 2012). However, the scientific literature has not established whether myofascial trigger points from different underlying diseases have the same clinical characteristics. The hypothesis of the present study is that the myofascial pain in breast cancer survivors produce more intense symptoms than in women with neck pain, due to a greater severity of disease and extent of the injury caused by the surgical and adjuvant treatment to which breast cancer survivors are subjected; the clinical approach commonly used for the treatment of these patients is based on surgical procedures that involve the muscles of the thorax, mainly the pectoralis major and minor. Moreover, depending on the aggressiveness of the neoplasia, local and systemic treatments such as radiotherapy and chemotherapy may be instituted (Cheville and Tchou, 2007). Given the above, the objective of the present study was to compare the intensity of myofascial pain, catastrophizing, and the pressure pain threshold at myofascial trigger points among breast cancer survivors and women with neck pain.
Care for the Rehabilitation of Mastectomized Women, who were over 18 years old and complaining of myofascial pain in the upper trapezius muscle region for more than 90 days. The patients had previously undergone treatment for breast cancer (surgery, chemotherapy, and/or radiation therapy) that was completed at least six months prior. In addition to the criteria for exclusion from the group with neck pain, the presence of metastasis or recurrence of breast cancer and bilateral mastectomy were also added. 2.3. Diagnosis of the myofascial trigger points In addition to the above eligibility criteria, both the women with neck pain and the breast cancer survivors had to have an active myofascial trigger point in the upper trapezius muscle, located at a mean distance from C7 to the acromion and diagnosed according to the criteria established by Simons et al. (1999) and Gerwin et al. (1997): the presence of a taut band in the skeletal muscle, the presence of a hypersensitive point within the taut band, local contraction in response to palpation of the taut band, and reproduction of the referred pain due to compression of up to 2.5 kg/cm2 on the trigger point (Ziaeifar et al., 2014). It should be pointed out that these diagnostic criteria for the myofascial trigger points have acceptable levels of reliability, with kappa values of 0.36e0.88 (Gerwin et al., 1997). The physiotherapist responsible for the diagnosis of the myofascial trigger points had eight years of experience with myofascial pain at that time and had received previous training, for a period of three months, with the tools employed in the present study.
2. Methods 2.4. Assessment procedures 2.1. Research setup This was a cross-sectional study in which a physiotherapist was responsible for recruiting patients, determining eligibility, diagnosing the myofascial trigger points, and performing pressure pain threshold evaluation. Another physiotherapist evaluated the pain intensity and catastrophizing. A third physiotherapist carried out data processing and analysis. 2.2. Ethical aspects and recruitment The study was approved by the Research Ethics Committee of ~o Preto of the the Clinics Hospital of the Medical School of Ribeira ~o Paulo, under opinion number 475918/2013. The University of Sa recruitment of neck pain subjects to participate of this study occurred through verbal invitation and publicity, using posters, radio, and social media. Breast cancer survivors were verbally invited, or contacted through phone calls from the Center of Teaching, Research, and Care for the Rehabilitation of Mastectomized Women of the Ribeir~ ao Preto School of Nursing at the Uni~o Paulo (SP, Brazil). All volunteers validated their versity of Sa participation in the study by signing a consent form. The recruitment of women with neck pain took place in the city of Ribeir~ ao Preto (SP, Brazil). Subjects were over 18 years old, complained of myofascial pain in the cervical region for more than 90 days (Walker et al., 2008), and had a score in the Neck Disability Index (NDI) of 5 points (Vernon and Mior, 1991; Cook et al., 2006). The exclusion criteria used in this study were as follows: history of head, face, or neck surgery; trauma in the neck, cervical disc herniation, or degenerative diseases of the spine; physical therapy in the previous three months; use of an analgesic, anti-inflammatory, or muscle relaxant in the previous week; the presence of systemic diseases; or a medical diagnosis of fibromyalgia. The breast cancer survivors included women were those who were receiving follow up at the Center of Teaching, Research, and
The sample was evaluated in a reserved room conducted by a physiotherapist and the assessments were carried out in person using hard copy. 2.5. Numeric Rating Scale (NRS) This is a simple scale, of easy measurement, and validated for the Portuguese language (Ferreira-Valente et al., 2011). It consists of a sequence of numbers, 0 to 10, in which the value 0 represents “no pain” and the numeral 10 represents “worst pain imaginable.” In this way, the volunteers rated their pain intensity in the upper trapezius muscle region based on these parameters. 2.6. Pain-Related Self-Statement Scale (PRSS) This scale was used to evaluate the catastrophic thoughts based on cognitive concepts and automatic thoughts present in individuals with chronic pain, which was developed by Flor et al. (1993) and adapted and validated for the Brazilian population by Sard a Junior et al. (2008). The scale consists of nine items, rated by a Likert scale ranging from 0 to 5 points, with the words “seldom” and “almost always” at the ends. The total score was the sum of the items divided by the number of items answered, and the minimum score could be 0 and the maximum 5. There were no cutoff points and higher scores indicated a greater presence of catastrophic thoughts. 2.7. Algometry An algometer (model PTR-300, Instrutherm, S~ ao Paulo, SP, Brazil) was used to measure the pressure pain threshold. To do this, the volunteers sat in a chair with the torso upright, the back fully supported, feet flat on the floor, and hands resting on the legs. A previously trained examiner positioned the tip of the algometer
Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012
A.V. Dibai-Filho et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e5
(with a rubber disc of 1 cm2) and exerted gradual compression at a constant speed of approximately 0.5 kg/cm2/s, controlled by audible feedback from a digital metronome (Gonçalves et al., 2015), perpendicularly to the upper trapezius muscle fibers, bilaterally, exactly on the myofascial trigger points. These points were pressed up to the intensity at which the volunteer reported pain, and the amount seen on the equipment's display was recorded in kg/cm2. The measurement of the pressure pain threshold was performed three times for each muscle, and the average value was calculated. This evaluation presents acceptable intraclass correlation coefficient (ICC) values of 0.88e0.90 and 0.74e0.89 for intra- and interrater reliability, respectively (Nussbaum and Downes, 1998). The pressure pain threshold was measured at the myofascial trigger points on the dominant and non-dominant sides in women with neck pain and on the sides operated on and not operated on in breast cancer survivors. 2.8. Statistical analysis A verification of the data distribution was performed using the Shapiro-Wilk test. Given the non-normal distribution, the MannWhitney test was applied for comparisons between groups, and the significance level adopted was 5%. The processing was done m, PA, Brazil). using BioEstat software, version 5.3 (Bele 3. Results Sixty volunteers were recruited: 30 with neck pain and 30 breast cancer survivors. There was no sample loss in the present study. The volunteers with neck pain had a median age of 22.00 years (first quartile [1Q] ¼ 20.00, third quartile [3Q] ¼ 24.00), a median BMI of 21.22 kg/m2 (1Q ¼ 20.83, 3Q ¼ 24.43), a median chronicity of 36.00 months (1Q ¼ 21.00, 3Q ¼ 60.00), and a median score on the NDI of 11.00 points (1Q ¼ 7.25, 3Q ¼ 13.75). On the other hand, the volunteer breast cancer survivors had a median age of 54.00 years (1Q ¼ 49.50, 3Q ¼ 58.57), a median BMI of 29.69 kg/ m2 (1Q ¼ 27.10, 3Q ¼ 31.67), and a median chronicity of 23.50 months (1Q ¼ 8.00, 3Q ¼ 46.50). Thus, by applying the MannWhitney test to compare these variables between the groups, significant differences were observed in age (p < 0.001) and BMI (p < 0.001). Table 1 shows the comparison of the intensity of pain, catastrophizing, and the pressure pain threshold on the myofascial trigger points among women with neck pain and breast cancer survivors. There was a significant difference only in the comparison of pain intensity (p < 0.001, Mann-Whitney test). 4. Discussion Myofascial pain can affect different populations. The present study investigated the clinical characteristics of this pain in women
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with neck pain and breast cancer survivors. A significant difference was observed in the intensity of the pain, with higher scores in the group of patients who had undergone breast cancer treatment. Furthermore, it should be pointed out that there was no difference between the groups in catastrophizing and in the pressure pain threshold on myofascial trigger points in the upper trapezius muscle. Regarding the assessment of pain, Colhado et al. (2013) highlighted the complexity of measurement of this clinical condition when they pointed out the various aspects involved, including the psychophysical approach and qualitative, subjective, emotional, motivational, and cultural components. Because of this, this present study evaluated three aspects of pain (intensity of pain, catastrophizing, and the pressure pain threshold on the myofascial trigger points) in order to better understand the characteristics of the pain in both populations studied here. Central and peripheral sensitization in chronic myofascial pain ndez-de-las-Pen ~ as and has been the object of a recent study (Ferna Dommerholt, 2014). According to these authors, the presence of central sensitization in patients with myofascial trigger points is mainly related to the phenomenon of referred pain, which is pain felt in a region away from the source of pain. However, these authors point out that referred pain elicited by myofascial trigger points is a central phenomenon that is initiated, activated, and maintained by peripheral sensitization. Based on the values of normality of the algometry established by Chesterton et al. (2003), this study evaluated the pressure pain threshold on myofascial trigger points and observed lower thresholds in both groups, thereby indicating peripheral sensitization (Hübscher et al., 2013). An instrument was not used in the present study for assessing central sensitization in particular. However, some studies suggest that individuals with higher pain intensity tend to exhibit central sensitization (Hübscher et al., 2013; Lee et al., 2008). Therefore, the present study considers it likely that the two groups show central sensitization based on the presence of myofascial trigger points and ~ as to the phenomenon of the referred pain (Fern andez-de-las-Pen and Dommerholt, 2014; Arendt-Nielsen and Svensson, 2001). However, this central involvement appears more pronounced in breast cancer survivors because of the higher pain intensity. In addition, considering individuals with cervical dysfunction, ndez-Pe rez et al. (2012) observed that patients with high level Ferna of disability related to acute whiplash injury exhibited widespread pain sensitivity, which is interpreted as a sign of central sensitization. Freeman et al. (2009) also observed central sensitization in patients with chronic whiplash. It should also be mentioned that ndez-Pe rez et al. (2012) and Freeman et al. (2009) considered Ferna the presence of myofascial trigger points in their studies. In contrast, a systematic review conducted by Malfliet et al. (2015) concluded that central sensitization is not a characteristic feature of chronic idiopathic and non-traumatic neck pain, but can be present in some individuals of the population. In contrast, previous
Table 1 Comparison of the intensity of pain, catastrophizing, and the pressure pain threshold between women with neck pain (n ¼ 30) and breast cancer survivors (n ¼ 30). Variables
Neck pain
NRS (score) PRSS (score) PPTnd versus PPTop (kg/cm2) PPTnd versus PPTno (kg/cm2) PPTdo versus PPTop (kg/cm2) PPTdo versus PPTno (kg/cm2)
2.50 0.77 1.42 1.42 1.49 1.49
(2.00, (0.33, (1.27, (1.27, (1.33, (1.33,
4.00) 1.85) 1.79) 1.79) 1.91) 1.91)
Breast cancer survivors
p value
8.00 1.16 1.50 1.62 1.50 1.62
<0.0001* 0.340 0.248 0.865 0.126 0.947
(7.00, (0.33, (0.83, (1.09, (0.83, (1.09,
8.75) 1.91) 1.76) 2.11) 1.76) 2.11)
Numbers are presented as follows: median (first quartile, third quartile). NRS: Numeric Rating Scale; PRSS: Pain-Related Self-Statement Scale; PPTnd: pressure pain threshold nondominant side; PPTdo: pressure pain threshold dominant side; PPTop: pressure pain threshold operated side; PPTno: pressure pain threshold nonoperated side. *Statistically significant difference (p < 0.05, Mann-Whitney test).
Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012
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investigations indicated the presence of central sensitization in ndez-Lao et al. (2011) investigated breast cancer survivors. Ferna the behavior of pain in breast cancer survivors subjected to two different types of surgery (lumpectomy or mastectomy) and identified the presence of central sensitization in the patients regardless of the type of surgery used. Also along these lines, Steegers et al. (2008) indicated that nerve injury is particularly efficient at producing central sensitization in breast cancer survivors who have undergone breast surgery and axillary lymph node dissection. Regarding psychosocial aspects, in the present study there was no significant difference between groups in catastrophizing, but the breast cancer survivors presented a median value higher than the women with neck pain. It is known that psychosocial factors can interfere in the intensity of pain, so it is therefore important to calculate and measure these aspects (Vranceanu et al., 2009). Previous research reported the presence of catastrophizing in both populations studied here (Belfer et al., 2013; Dimitriadis et al., 2015). Therefore, other psychosocial aspects should be considered in future studies comparing myofascial pain in different populations, such as depressive symptoms, anxiety, sleep, perceived stress, emotional stability, and somatization (Belfer et al., 2013). The present study has some limitations. We suggest that future research compares other populations with myofascial trigger points and that other instruments be used to assess the repercussion of the myofascial pain on aspects such as central sensitization, functional capacity, quality of life, and psychological factors. In addition, one aspect worth noting in the present study is that the average age and BMI were significantly different between the groups. This limitation occurred due to the recruitment sites of study participants. However, despite these logistic aspects, it is common to find similar values of age and body mass in studies investigating myofascial pain in patients with neck pain (Dibai Filho et al., 2012; Llamas-Ramos et al., 2014) and breast cancer survivors (Torres Lacomba et al., 2010; Cantarero-Villanueva et al., 2012). However, without diminishing the importance of the present study for comparing myofascial pain in these populations, other authors may consider pairing the samples for anthropometric and demographic characteristics in the development of future investigations. Additionally, our study did not investigate the presence of neck pain in breast cancer survivors. Therefore, this aspect must be considered by clinicians and researchers. 5. Conclusion According to the results obtained regarding myofascial dysfunction, it was observed in the present study that breast cancer survivors have a higher intensity of pain in the upper trapezius muscle compared to compared to women with neck pain, which indicates the need for evaluation and a specific intervention for the myofascial dysfunction of these women. Competing interests The authors have declared that no competing interests exist. Acknowledgments ~o Paulo Research Foundation (FAPESP, grants 2013/19368-8 Sa and 2013/09753-1) and Coordination for the Improvement of Higher Education Personnel (CAPES). References Arendt-Nielsen, L., Svensson, P., 2001. Referred muscle pain: basic and clinical findings. Clin. J. Pain 17, 11e19.
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Tali, D., Menahem, I., Vered, E., Kalichman, L., 2014. Upper cervical mobility, posture and myofascial trigger points in subjects with episodic migraine: case-control study. J. Bodyw. Mov. Ther. 18, 569e575. Torres Lacomba, M., Mayoral del Moral, O., Coperias Zazo, J.L., Gerwin, R.D., ~ í, A.Z., 2010. Incidence of myofascial pain syndrome in breast cancer surGon gery: a prospective study. Clin. J. Pain 26, 320e325. Vernon, H., Mior, S., 1991. The Neck Disability Index: a study of reliability and validity. J. Manip. Physiol. Ther. 14, 409e415. Vranceanu, A.M., Barsky, A., Ring, D., 2009. Psychosocial aspects of disabling musculoskeletal pain. J. Bone Jt. Surg. Am. 91, 2014e2018. Walker, M.J., Boyles, R.E., Young, B.A., Strunce, J.B., Garber, M.B., Whitman, J.M., et al., 2008. The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine 33, 2371e2378. Zakharova-Luneva, E., Jull, G., Johnston, V., O'Leary, S., 2012. Altered trapezius muscle behavior in individuals with neck pain and clinical signs of scapular dysfunction. J. Manip. Physiol. Ther. 35, 346e353. Ziaeifar, M., Arab, A.M., Karimi, N., Nourbakhsh, M.R., 2014. The effect of dry needling on pain, pressure pain threshold and disability in patients with a myofascial trigger point in the upper trapezius muscle. J. Bodyw. Mov. Ther. 18, 298e305.
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Original research
Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain Almir Vieira Dibai-Filho, PT, PhD a, Rinaldo Roberto de Jesus Guirro, PT, PhD a, ^nia Tie Koga Ferreira, PT, PhD a, Alessandra Kelly de Oliveira, PT a, Va Ana Maria de Almeida, RN, PhD b, Elaine Caldeira de Oliveira Guirro, PT, PhD a, * a
Postgraduate Program in Rehabilitation and Functional Performance, Department of Biomechanics, Medicine, and Rehabilitation of the Locomotor ~o Preto, University of Sa ~o Paulo, Ribeira ~o Preto, SP, Brazil Apparatus, Medical School of Ribeira ~o Preto, University Postgraduate Program in Nursing in Public Health, Department of Maternal-Infant and Public Health Nursing, Nursing School of Ribeira ~o Paulo, Ribeira ~o Preto, SP, Brazil of Sa b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 January 2017 Received in revised form 20 April 2017 Accepted 25 April 2017
Myofascial trigger points are present in dysfunctioning muscles and are associated with several diseases. However, the scientific literature has not established whether myofascial trigger points of differing etiologies have the same clinical characteristics. Thus, the objective of the present study was to compare the intensity of myofascial pain, catastrophizing, and the pressure pain threshold at myofascial trigger points among breast cancer survivors and women with neck pain. This was a cross-sectional study that included women over 18 years old complaining of myofascial pain in the upper trapezius muscle region for more than 90 days, equally divided into breast cancer survivors (n ¼ 30) and those with neck pain (n ¼ 30). For inclusion, the presence of a bilateral, active, and centrally located trigger point with mean distance from C7 to acromion in the upper trapezius was mandatory. The measures of assessment were: pain intensity, catastrophizing, and the pressure pain threshold at the myofascial trigger points. A significant difference was observed only when comparing pain intensity (p < 0.001) between the breast cancer survivors (median score: 8.00 points, first quartile: 7.00 points, third quartile: 8.75 points) and women with neck pain (median score: 2.50 points, first quartile: 2.00 points, third quartile: 4.00 points). No significant difference was found between groups in catastrophizing and pressure pain threshold. The conclusion of this study was that breast cancer survivors have a higher intensity of myofascial pain in the upper trapezius muscle when compared to patients with neck pain, which indicates the need for evaluation and a specific intervention for the myofascial dysfunction of these women. © 2017 Published by Elsevier Ltd.
Keywords: Myofascial pain syndromes Muscle Skeletal Chronic pain
1. Introduction Myofascial trigger points are pathological structures present in skeletal muscles and are related to sensory, motor, and autonomic changes (Bron and Dommerholt, 2012). They are defined as palpable nodules located in the taut band of a muscle. They also produce local and referred pain and may be active or latent (Ge and Arendt-Nielsen, 2011; Bron and Dommerholt, 2012). Moreover, metabolic (Larsson et al., 2008), vascular (Larsson et al., 1999), and
~o Paulo, Faculdade de Medicina de * Corresponding author. Universidade de Sa ~o Preto, Pre dio da Fisioterapia e Terapia Ocupacional, Avenida dos BandeirRibeira ~o Preto CEP 14049-900, SP, Brazil. antes, 3900, Monte Alegre, Ribeira E-mail address: [email protected] (E.C. de Oliveira Guirro).
electromyographic changes (Zakharova-Luneva et al., 2012) can also be observed in these dysfunctioning tissues. In pathophysiological terms, it is hypothesised that there is a metabolic impairment in this clinical condition, because the increase in muscular activity produces an increase in intramuscular pressure with subsequent mechanical compression of the blood vessels in the muscle; because of this, a series of cascading events are thought to occur, such as a reduction in the supply of oxygen and glucose, ineffective aerobic metabolism, activation of anaerobic metabolism for the formation of adenosine triphosphate, the buildup of lactic acid, a reduction in intramuscular hydrogenionic potential, a reduction in acetylcholinesterase activity and increased acetylcholine action, an increase in the concentration of intracellular calcium, stronger interactions between actin and myosin,
http://dx.doi.org/10.1016/j.jbmt.2017.04.012 1360-8592/© 2017 Published by Elsevier Ltd.
Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012
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A.V. Dibai-Filho et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e5
inflammation, and muscle damage (Bron and Dommerholt, 2012; Moraska et al., 2013). Myofascial trigger points are present in dysfunctioning muscles and are associated with several, conditions such as temporomanndez-de-Las-Pen ~ as et al., 2010), lower back dibular disorder (Ferna pain (Iglesias-Gonz alez et al., 2013), shoulder impingement syndrome (Delgado-Gil et al., 2015), and migraine (Tali et al., 2014), even affecting individuals with neck pain (Dibai-Filho et al., 2015) and breast cancer survivors (Cantarero-Villanueva et al., 2012). However, the scientific literature has not established whether myofascial trigger points from different underlying diseases have the same clinical characteristics. The hypothesis of the present study is that the myofascial pain in breast cancer survivors produce more intense symptoms than in women with neck pain, due to a greater severity of disease and extent of the injury caused by the surgical and adjuvant treatment to which breast cancer survivors are subjected; the clinical approach commonly used for the treatment of these patients is based on surgical procedures that involve the muscles of the thorax, mainly the pectoralis major and minor. Moreover, depending on the aggressiveness of the neoplasia, local and systemic treatments such as radiotherapy and chemotherapy may be instituted (Cheville and Tchou, 2007). Given the above, the objective of the present study was to compare the intensity of myofascial pain, catastrophizing, and the pressure pain threshold at myofascial trigger points among breast cancer survivors and women with neck pain.
Care for the Rehabilitation of Mastectomized Women, who were over 18 years old and complaining of myofascial pain in the upper trapezius muscle region for more than 90 days. The patients had previously undergone treatment for breast cancer (surgery, chemotherapy, and/or radiation therapy) that was completed at least six months prior. In addition to the criteria for exclusion from the group with neck pain, the presence of metastasis or recurrence of breast cancer and bilateral mastectomy were also added. 2.3. Diagnosis of the myofascial trigger points In addition to the above eligibility criteria, both the women with neck pain and the breast cancer survivors had to have an active myofascial trigger point in the upper trapezius muscle, located at a mean distance from C7 to the acromion and diagnosed according to the criteria established by Simons et al. (1999) and Gerwin et al. (1997): the presence of a taut band in the skeletal muscle, the presence of a hypersensitive point within the taut band, local contraction in response to palpation of the taut band, and reproduction of the referred pain due to compression of up to 2.5 kg/cm2 on the trigger point (Ziaeifar et al., 2014). It should be pointed out that these diagnostic criteria for the myofascial trigger points have acceptable levels of reliability, with kappa values of 0.36e0.88 (Gerwin et al., 1997). The physiotherapist responsible for the diagnosis of the myofascial trigger points had eight years of experience with myofascial pain at that time and had received previous training, for a period of three months, with the tools employed in the present study.
2. Methods 2.4. Assessment procedures 2.1. Research setup This was a cross-sectional study in which a physiotherapist was responsible for recruiting patients, determining eligibility, diagnosing the myofascial trigger points, and performing pressure pain threshold evaluation. Another physiotherapist evaluated the pain intensity and catastrophizing. A third physiotherapist carried out data processing and analysis. 2.2. Ethical aspects and recruitment The study was approved by the Research Ethics Committee of ~o Preto of the the Clinics Hospital of the Medical School of Ribeira ~o Paulo, under opinion number 475918/2013. The University of Sa recruitment of neck pain subjects to participate of this study occurred through verbal invitation and publicity, using posters, radio, and social media. Breast cancer survivors were verbally invited, or contacted through phone calls from the Center of Teaching, Research, and Care for the Rehabilitation of Mastectomized Women of the Ribeir~ ao Preto School of Nursing at the Uni~o Paulo (SP, Brazil). All volunteers validated their versity of Sa participation in the study by signing a consent form. The recruitment of women with neck pain took place in the city of Ribeir~ ao Preto (SP, Brazil). Subjects were over 18 years old, complained of myofascial pain in the cervical region for more than 90 days (Walker et al., 2008), and had a score in the Neck Disability Index (NDI) of 5 points (Vernon and Mior, 1991; Cook et al., 2006). The exclusion criteria used in this study were as follows: history of head, face, or neck surgery; trauma in the neck, cervical disc herniation, or degenerative diseases of the spine; physical therapy in the previous three months; use of an analgesic, anti-inflammatory, or muscle relaxant in the previous week; the presence of systemic diseases; or a medical diagnosis of fibromyalgia. The breast cancer survivors included women were those who were receiving follow up at the Center of Teaching, Research, and
The sample was evaluated in a reserved room conducted by a physiotherapist and the assessments were carried out in person using hard copy. 2.5. Numeric Rating Scale (NRS) This is a simple scale, of easy measurement, and validated for the Portuguese language (Ferreira-Valente et al., 2011). It consists of a sequence of numbers, 0 to 10, in which the value 0 represents “no pain” and the numeral 10 represents “worst pain imaginable.” In this way, the volunteers rated their pain intensity in the upper trapezius muscle region based on these parameters. 2.6. Pain-Related Self-Statement Scale (PRSS) This scale was used to evaluate the catastrophic thoughts based on cognitive concepts and automatic thoughts present in individuals with chronic pain, which was developed by Flor et al. (1993) and adapted and validated for the Brazilian population by Sard a Junior et al. (2008). The scale consists of nine items, rated by a Likert scale ranging from 0 to 5 points, with the words “seldom” and “almost always” at the ends. The total score was the sum of the items divided by the number of items answered, and the minimum score could be 0 and the maximum 5. There were no cutoff points and higher scores indicated a greater presence of catastrophic thoughts. 2.7. Algometry An algometer (model PTR-300, Instrutherm, S~ ao Paulo, SP, Brazil) was used to measure the pressure pain threshold. To do this, the volunteers sat in a chair with the torso upright, the back fully supported, feet flat on the floor, and hands resting on the legs. A previously trained examiner positioned the tip of the algometer
Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012
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(with a rubber disc of 1 cm2) and exerted gradual compression at a constant speed of approximately 0.5 kg/cm2/s, controlled by audible feedback from a digital metronome (Gonçalves et al., 2015), perpendicularly to the upper trapezius muscle fibers, bilaterally, exactly on the myofascial trigger points. These points were pressed up to the intensity at which the volunteer reported pain, and the amount seen on the equipment's display was recorded in kg/cm2. The measurement of the pressure pain threshold was performed three times for each muscle, and the average value was calculated. This evaluation presents acceptable intraclass correlation coefficient (ICC) values of 0.88e0.90 and 0.74e0.89 for intra- and interrater reliability, respectively (Nussbaum and Downes, 1998). The pressure pain threshold was measured at the myofascial trigger points on the dominant and non-dominant sides in women with neck pain and on the sides operated on and not operated on in breast cancer survivors. 2.8. Statistical analysis A verification of the data distribution was performed using the Shapiro-Wilk test. Given the non-normal distribution, the MannWhitney test was applied for comparisons between groups, and the significance level adopted was 5%. The processing was done m, PA, Brazil). using BioEstat software, version 5.3 (Bele 3. Results Sixty volunteers were recruited: 30 with neck pain and 30 breast cancer survivors. There was no sample loss in the present study. The volunteers with neck pain had a median age of 22.00 years (first quartile [1Q] ¼ 20.00, third quartile [3Q] ¼ 24.00), a median BMI of 21.22 kg/m2 (1Q ¼ 20.83, 3Q ¼ 24.43), a median chronicity of 36.00 months (1Q ¼ 21.00, 3Q ¼ 60.00), and a median score on the NDI of 11.00 points (1Q ¼ 7.25, 3Q ¼ 13.75). On the other hand, the volunteer breast cancer survivors had a median age of 54.00 years (1Q ¼ 49.50, 3Q ¼ 58.57), a median BMI of 29.69 kg/ m2 (1Q ¼ 27.10, 3Q ¼ 31.67), and a median chronicity of 23.50 months (1Q ¼ 8.00, 3Q ¼ 46.50). Thus, by applying the MannWhitney test to compare these variables between the groups, significant differences were observed in age (p < 0.001) and BMI (p < 0.001). Table 1 shows the comparison of the intensity of pain, catastrophizing, and the pressure pain threshold on the myofascial trigger points among women with neck pain and breast cancer survivors. There was a significant difference only in the comparison of pain intensity (p < 0.001, Mann-Whitney test). 4. Discussion Myofascial pain can affect different populations. The present study investigated the clinical characteristics of this pain in women
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with neck pain and breast cancer survivors. A significant difference was observed in the intensity of the pain, with higher scores in the group of patients who had undergone breast cancer treatment. Furthermore, it should be pointed out that there was no difference between the groups in catastrophizing and in the pressure pain threshold on myofascial trigger points in the upper trapezius muscle. Regarding the assessment of pain, Colhado et al. (2013) highlighted the complexity of measurement of this clinical condition when they pointed out the various aspects involved, including the psychophysical approach and qualitative, subjective, emotional, motivational, and cultural components. Because of this, this present study evaluated three aspects of pain (intensity of pain, catastrophizing, and the pressure pain threshold on the myofascial trigger points) in order to better understand the characteristics of the pain in both populations studied here. Central and peripheral sensitization in chronic myofascial pain ndez-de-las-Pen ~ as and has been the object of a recent study (Ferna Dommerholt, 2014). According to these authors, the presence of central sensitization in patients with myofascial trigger points is mainly related to the phenomenon of referred pain, which is pain felt in a region away from the source of pain. However, these authors point out that referred pain elicited by myofascial trigger points is a central phenomenon that is initiated, activated, and maintained by peripheral sensitization. Based on the values of normality of the algometry established by Chesterton et al. (2003), this study evaluated the pressure pain threshold on myofascial trigger points and observed lower thresholds in both groups, thereby indicating peripheral sensitization (Hübscher et al., 2013). An instrument was not used in the present study for assessing central sensitization in particular. However, some studies suggest that individuals with higher pain intensity tend to exhibit central sensitization (Hübscher et al., 2013; Lee et al., 2008). Therefore, the present study considers it likely that the two groups show central sensitization based on the presence of myofascial trigger points and ~ as to the phenomenon of the referred pain (Fern andez-de-las-Pen and Dommerholt, 2014; Arendt-Nielsen and Svensson, 2001). However, this central involvement appears more pronounced in breast cancer survivors because of the higher pain intensity. In addition, considering individuals with cervical dysfunction, ndez-Pe rez et al. (2012) observed that patients with high level Ferna of disability related to acute whiplash injury exhibited widespread pain sensitivity, which is interpreted as a sign of central sensitization. Freeman et al. (2009) also observed central sensitization in patients with chronic whiplash. It should also be mentioned that ndez-Pe rez et al. (2012) and Freeman et al. (2009) considered Ferna the presence of myofascial trigger points in their studies. In contrast, a systematic review conducted by Malfliet et al. (2015) concluded that central sensitization is not a characteristic feature of chronic idiopathic and non-traumatic neck pain, but can be present in some individuals of the population. In contrast, previous
Table 1 Comparison of the intensity of pain, catastrophizing, and the pressure pain threshold between women with neck pain (n ¼ 30) and breast cancer survivors (n ¼ 30). Variables
Neck pain
NRS (score) PRSS (score) PPTnd versus PPTop (kg/cm2) PPTnd versus PPTno (kg/cm2) PPTdo versus PPTop (kg/cm2) PPTdo versus PPTno (kg/cm2)
2.50 0.77 1.42 1.42 1.49 1.49
(2.00, (0.33, (1.27, (1.27, (1.33, (1.33,
4.00) 1.85) 1.79) 1.79) 1.91) 1.91)
Breast cancer survivors
p value
8.00 1.16 1.50 1.62 1.50 1.62
<0.0001* 0.340 0.248 0.865 0.126 0.947
(7.00, (0.33, (0.83, (1.09, (0.83, (1.09,
8.75) 1.91) 1.76) 2.11) 1.76) 2.11)
Numbers are presented as follows: median (first quartile, third quartile). NRS: Numeric Rating Scale; PRSS: Pain-Related Self-Statement Scale; PPTnd: pressure pain threshold nondominant side; PPTdo: pressure pain threshold dominant side; PPTop: pressure pain threshold operated side; PPTno: pressure pain threshold nonoperated side. *Statistically significant difference (p < 0.05, Mann-Whitney test).
Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012
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investigations indicated the presence of central sensitization in ndez-Lao et al. (2011) investigated breast cancer survivors. Ferna the behavior of pain in breast cancer survivors subjected to two different types of surgery (lumpectomy or mastectomy) and identified the presence of central sensitization in the patients regardless of the type of surgery used. Also along these lines, Steegers et al. (2008) indicated that nerve injury is particularly efficient at producing central sensitization in breast cancer survivors who have undergone breast surgery and axillary lymph node dissection. Regarding psychosocial aspects, in the present study there was no significant difference between groups in catastrophizing, but the breast cancer survivors presented a median value higher than the women with neck pain. It is known that psychosocial factors can interfere in the intensity of pain, so it is therefore important to calculate and measure these aspects (Vranceanu et al., 2009). Previous research reported the presence of catastrophizing in both populations studied here (Belfer et al., 2013; Dimitriadis et al., 2015). Therefore, other psychosocial aspects should be considered in future studies comparing myofascial pain in different populations, such as depressive symptoms, anxiety, sleep, perceived stress, emotional stability, and somatization (Belfer et al., 2013). The present study has some limitations. We suggest that future research compares other populations with myofascial trigger points and that other instruments be used to assess the repercussion of the myofascial pain on aspects such as central sensitization, functional capacity, quality of life, and psychological factors. In addition, one aspect worth noting in the present study is that the average age and BMI were significantly different between the groups. This limitation occurred due to the recruitment sites of study participants. However, despite these logistic aspects, it is common to find similar values of age and body mass in studies investigating myofascial pain in patients with neck pain (Dibai Filho et al., 2012; Llamas-Ramos et al., 2014) and breast cancer survivors (Torres Lacomba et al., 2010; Cantarero-Villanueva et al., 2012). However, without diminishing the importance of the present study for comparing myofascial pain in these populations, other authors may consider pairing the samples for anthropometric and demographic characteristics in the development of future investigations. Additionally, our study did not investigate the presence of neck pain in breast cancer survivors. Therefore, this aspect must be considered by clinicians and researchers. 5. Conclusion According to the results obtained regarding myofascial dysfunction, it was observed in the present study that breast cancer survivors have a higher intensity of pain in the upper trapezius muscle compared to compared to women with neck pain, which indicates the need for evaluation and a specific intervention for the myofascial dysfunction of these women. Competing interests The authors have declared that no competing interests exist. Acknowledgments ~o Paulo Research Foundation (FAPESP, grants 2013/19368-8 Sa and 2013/09753-1) and Coordination for the Improvement of Higher Education Personnel (CAPES). References Arendt-Nielsen, L., Svensson, P., 2001. Referred muscle pain: basic and clinical findings. Clin. J. Pain 17, 11e19.
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Please cite this article in press as: Dibai-Filho, A.V., et al., Analysis of chronic myofascial pain in the upper trapezius muscle of breast cancer survivors and women with neck pain, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.04.012