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Posted to Co-Cure Tue, 4 May 2004 15:28:37 -0400 by LK Woodruff

Cortisol and hypothalamic-pituitary-gonadal axis hormones in follicular-phase women with fibromyalgia and chronic fatigue syndrome and effect of depressive symptoms on these hormones

Full Title: Cortisol and hypothalamic-pituitary-gonadal axis hormones in follicular-phase women with fibromyalgia and chronic fatigue syndrome and effect of depressive symptoms on these hormones.

Journal:Arthritis Res Ther. 2004;6(3):R232-8. Epub 2004 Mar 15.

Authors:Gur A, Cevik R, Nas K, Colpan L, Sarac S.

Affiliation:Department of Physical Medicine and Rehabilitation, School of Medicine, Dicle University, Diyarbakir, Turkey. alig@dicle.edu.tr

NLM Citation: PMID: 15142269

We investigated abnormalities of the hypothalamic-pituitary-gonadal axis and cortisol concentrations in women with fibromyalgia and chronic fatigue syndrome (CFS) who were in the follicular phase of their menstrual cycle, and whether their scores for depressive symptoms were related to levels of these hormones.

A total of 176 subjects participated - 46 healthy volunteers, 68 patients with fibromyalgia, and 62 patients with CFS. We examined concentrations of follicle-stimulating hormone, luteinizing hormone (LH), estradiol, progesterone, prolactin, and cortisol. Depressive symptoms were assessed using the Beck Depression Inventory (BDI).

Cortisol levels were significantly lower in patients with fibromyalgia or CFS than in healthy controls (P < 0.05); there were no significant differences in other hormone levels between the three groups.Fibromyalgia patients with high BDI scores had significantly lower cortisol levels than controls (P < 0.05), and so did CFS patients, regardless of their BDI scores (P < 0.05). Among patients without depressive symptoms, cortisol levels were lower in CFS than in fibromyalgia (P < 0.05).

Our study suggests that in spite of low morning cortisol concentrations, the only abnormalities in hypothalamic-pituitary-gonadal axis hormones among follicular-phase women with fibromyalgia or CFS are those of LH levels in fibromyalgia patients with a low BDI score. Depression may lower cortisol and LH levels, or, alternatively, low morning cortisol may be a biological factor that contributes to depressive symptoms in fibromyalgia. These parameters therefore must be taken into account in future investigations.

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Posted to Co-Cure Wed, Thu, 26 Dec 2002 00:17:15 -0500 by Fred Springfield

Analysis of 16S rRNA gene sequences and circulating cell-free DNA from plasma of CFS and non-fatigued subjects

Full Title: Analysis of 16S rRNA gene sequences and circulating cell-free DNA from plasma of chronic fatigue syndrome and non-fatigued subjects.

Journal: BMC Microbiol 2002 Dec 23;2(1):39 [epub ahead of print]

Authors: Suzanne D. Vernon [1] , Sanjay K. Shukla [2] , Jennifer Conradt [2] , Elizabeth R. Unger [1] , William C. Reeves [1]

Affiliations: [1] Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, [2] Clinical Research Center, Marshfield Medical Research Foundation, 1000 North Oak Avenue, Marshfield WI 54449-5790

NLM Citation: PMID: 12498618

Background. The association of an infectious agent with chronic fatigue syndrome (CFS) has been difficult and is further complicated by the lack of a known lesion or diseased tissue. Cell-free plasma DNA could serve as a sentinel of infection and disease occurring throughout the body. This type of systemic sample coupled with broad-range amplification of bacterial sequences was used to determine whether a bacterial pathogen was associated with CFS. Plasma DNA from 34 CFS and 55 non-fatigued subjects was assessed to determine plasma DNA concentration and the presence of bacterial 16S ribosomal DNA (rDNA) sequences.

Results. DNA was isolated from 81 (91%) of 89 plasma samples. The 55 non-fatigued subjects had higher plasma DNA concentrations than those with CFS (average 151 versus 91 ng) and more CFS subjects (6/34, 18%) had no detectable plasma DNA than non-fatigued subjects (2/55, 4%), but these differences were not significant. Bacterial sequences were detected in 23 (26%) of 89. Only 4 (14%) CFS subjects had 16S rDNA sequences amplified from plasma compared with 17 (32%) of the non-fatigued (P = 0.03). All but 1 of the 23 16S rDNA amplicon-positive subjects had five or more unique sequences present.

Conclusions. CFS subjects had slightly lower concentrations or no detectable plasma DNA than non-fatigued subjects. There was a diverse array of 16S rDNA sequences in plasma DNA from both CFS and non-fatigued subjects. There were no unique, previously uncharacterized or predominant 16S rDNA sequences in either CFS or non-fatigued subjects. Uncharacterized prokaryotic sequences found.

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Posted to Co-Cure Wed, 13 Mar 2002 16:21:28 EST by Fred Springfield

Dynamics of chronic active herpesvirus-6 infection in patients with CFS...

Full Title: Dynamics of chronic active herpesvirus-6 infection in patients with chronic fatigue syndrome: data acquisition for computer modeling.

Journal: In Vivo 2001 Nov-Dec;15(6):461-5

Authors: Krueger GR, Koch B, Hoffmann A, Rojo J, Brandt ME, Wang G, Buja LM.

Affiliation: Department of Pathology & Laboratory Medicine, University of Texas-Houston Medical School, 6431 Fannin St, MSB 2.246, Houston, Texas 77030, USA. Gerhard.Krueger@uthtmc.edu

NLM Citation: PMID: 11887330

Ten adult patients with persistent active HHV-6 variant A infection and clinical chronic fatigue syndrome (CFS) were studied over a period of 24 months after initial clinical diagnosis. CFS was diagnosed according to IIIP-revised CDC-criteria as defined by the CFS Expert Advisory Group to the German Federal Ministry of Health in 1994.

Changes in HHV-6 antibody titer, viral DNA load, peripheral blood T lymphocytes and subpopulations, as well as CD4/CD8 cell ratio and cell death (apoptosis) were monitored. Data were collected for comparison with respective changes in acute HHV-6 infection and as a basis for future computer simulation studies.

The results showed variable but slightly elevated numbers of HHV-6 DNA copies in the blood of patients with CFS, while PBL (peripheral blood lymphocyte) apoptosis rates were clearly increased. CD4/CD8 cell ratios varied from below 1 up to values as seen in autoimmune disorders.

Contrary to acute HHV-6 infection, T lymphocytes do not exhibit the usual response to HHV-6, that is elevation of mature and immature populations suggesting a certain degree of unresponsiveness.

The data suggest that persistent low-dose stimulation by HHV-6 may favor imbalanced immune response rather than overt immune deficiency. This hypothesis requires confirmation through additional functional studies.

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Posted to Co-Cure Wed, 12 Dec 2001 11:55:39 -0600 by Fred Springfield

Hemodynamic instability in CFS: Indices and diagnostic significance

Full Title: Hemodynamic instability in chronic fatigue syndrome: Indices and diagnostic significance.

Journal: Semin Arthritis Rheum 2001 Dec;31(3):199-208

Authors: Naschitz JE, Sabo E, Naschitz S, Shaviv N, Rosner I, Rozenbaum M, Gaitini L, Ahdoot A, Ahdoot M, Priselac RM, Eldar S, Zukerman E, Yeshurun D.

Affiliations: Department of Internal Medicine A, Department of Rheumatology, Department of Anesthesiology, and Department of Surgery, Bnai Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.

NLM Citation: PMID: 11740800

OBJECTIVES: To evaluate the cardiovascular response to postural challenge in patients with chronic fatigue syndrome (CFS) and to determine whether the degree of instability of the cardiovascular response may aid in diagnosing CFS.

METHODS: Patients with CFS (n = 25) and their age- and gender-matched healthy controls (n = 37), patients with fibromyalgia (n = 30), generalized anxiety disorder (n = 15), and essential hypertension (n = 20) were evaluated with the aid of a standardized tilt test. The blood pressure (BP) and heart rate (HR) were recorded during 10 minutes of recumbence and 30 minutes of head-up tilt. We designated BP changes as the differences between successive BP values and the last recumbent BP. The average and standard deviation (SD) were calculated. Time curves of BP differences were loaded into a computerized image analyzer, and their outline ratios and fractal dimensions were measured. HR changes were determined similarly. The average and SD of the parameters were calculated, and intergroup comparisons were performed.

RESULTS: On multivariate analysis, the independent predictors of CFS patients versus healthy controls were the fractal dimension of absolute values of the systolic BP changes (SYST-FD.abs), the standard deviation of the current values of the systolic BP changes (SYST-SD.cur), and the standard deviation of the current values of the heart rate changes (HR-SD.cur). The following equation was deduced to calculate the hemodynamic instability score (HIS) in the individual patient: HIS = 64.3303 + (SYST-FD.abs x -68.0135) + (SYST-SD.cur x 111.3726) + (HR-SD.cur x 60.4164). The best cutoff differentiating CFS from the healthy controls was -0.98. HIS values >-0.98 were associated with CFS (sensitivity 97%, specificity 97%). The HIS differed significantly between CFS and other groups (P <.0001) except for generalized anxiety disorder. Group averages (SD) of HIS were CFS = +3.72 (5.02), healthy = -4.62 (2.26), fibromyalgia = -3.27 (2.63), hypertension = -5.53 (2.24), and generalized anxiety disorder = +1.08 (5.2).

CONCLUSION: The HIS adds objective criteria confirming the diagnosis of CFS.

Semin Arthritis Rheum 31:199-208. Copyright 2001 by W.B. Saunders Company

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Posted to Co-Cure Fri, 21 Sep 2001 15:16:07 -0400 by Alan C. Logan, ND

Widespread body pain and mortality: prospective population based study

Full Title: Widespread body pain and mortality: prospective population based study

Authors: Macfarlane GJ, McBeth J, Silman AJ

Affiliation: Unit of Chronic Disease Epidemiology, Medical School, University of Manchester, Manchester M13 9PT

NLM Citation: 11566829

Conclusion: There is an intriguing association between the report of widespread pain and subsequent death from cancer in the medium and long term. This may have implications for the long term follow up of patients with "unexplained" widespread pain symptoms, such as those with fibromyalgia.

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Posted to Co-Cure Sat, 21 Jul 2001 11:40:37 -0400 by Barbara J. Evans

CFS: Neurological findings may be related to blood-brain barrier permeability

Full Title: Chronic fatigue syndrome: neurological findings may be related to blood-brain barrier permeability.

Journal: Med Hypotheses 2001 Jul;57(2):231-7

Authors: Bested AC, Saunders PR, Logan AC.

Affiliation: Environmental Health Clinic, Sunnybrook and Women's College, Health Sciences Centre, Toronto, Canada

NLM Citation: PMID: 11461179

Despite volumes of international research, the etiology of chronic fatigue syndrome (CFS) remains elusive. There is, however, considerable evidence that CFS is a disorder involving the central nervous system (CNS). It is our hypothesis that altered permeability of the blood-brain barrier (BBB) may contribute to ongoing signs and symptoms found in CFS.

To support this hypothesis we have examined agents that can increase the blood-brain barrier permeability (BBBP) and those that may be involved in CFS.

The factors which can compromise the normal BBBP in CFS include viruses, cytokines, 5-hydroxytryptamine, peroxynitrite, nitric oxide, stress, glutathione depletion, essential fatty acid deficiency, and N-methyl-D-aspartate overactivity.

It is possible that breakdown of normal BBBP leads to CNS cellular dysfunction and disruptions of neuronal transmission in CFS. Abnormal changes in BBBP have been linked to a number of disorders involving the CNS; based on review of the literature we conclude that the BBB integrity in CFS warrants investigation.

Copyright 2001 Harcourt Publishers Ltd.

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Posted to Co-Cure Sat, 14 Jul 2001 20:27:50 -0400 by Co-Cure Moderators

Chronic Fatigue Syndrome: Comorbidity with Fibromyalgia and Psychiatric Illness

Full Title: Chronic Fatigue Syndrome: Comorbidity with Fibromyalgia and Psychiatric Illness

Journal: Medicine & Psychiatry, 2001, 4, 29-34.

Authors: Leonard A. Jason, Ph.D., Renée R. Taylor, Ph.D., Cara L. Kennedy, B.A. Sharon Song, M.A., Danielle Johnson, B.A., Susan Torres, M.A.

Affiliation: DePaul University

Abstract

Background: Pursuit of explanation for prior inconsistent physiological and psychological findings among individuals with CFS has led researchers to examine heterogeneity among patient samples that may result from the presence of comorbid illnesses. Most studies of Chronic Fatigue Syndrome (CFS) have been based on patients recruited from primary or tertiary care settings. Patients from such settings might not be typical of patients in the general population. Objectives: The present study was intended to examine differences between individuals with CFS with respect to comorbid Fibromyalgia and psychiatric illness.

Participants and Research Design: The present investigation involved examining individuals with CFS from a community-based study. A random sample of 18,675 respondents in Chicago was first interviewed by telephone. A group of individuals with chronic fatigue accompanied by at least four minor symptoms associated with CFS were given medical and psychiatric examinations. From this sample, a physician review group diagnosed individuals with CFS. Those diagnosed with CFS were subclassified based on a variety of categories, including comorbidity with Fibromyalgia and comorbidity with premorbid, lifetime, and current psychiatric diagnoses.

Results: Important differences emerged on measures of sociodemographics, symptoms, functional disability, stress, and coping. Individuals with CFS and comorbid Fibromyalgia demonstrated more symptom severity and functional impairment than individuals with CFS alone. Individuals with CFS and current or lifetime psychiatric diagnoses demonstrated greater fatigue and functional limitations.

Conclusions: Discrepancies among CFS research findings may be, in part, attributed to comorbidity with other medical and psychiatric illness.

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Posted to Co-Cure Sat, 14 Jul 2001 08:35:24 -0700 by Melissa O'Toole

Role of intracellular calcium ions in the physiopathology of fibromyalgia syndrome

Full Title: Role of intracellular calcium ions in the physiopathology of fibromyalgia syndrome.

Journal: Boll Soc Ital Biol Sper 2000 Jan-Feb;76(1-2):1-4

Authors: Magaldi M, Moltoni L, Biasi G, Marcolongo R.

Affiliation: Institute of Rheumatology, University of Siena, Policlinico Le Scotte, Viale Bracci 1, I-53100 Siena.

NLM Citation: PMID: 11449822

Calcium ions have a key role in the physiology of muscular contraction: changes in calcium ion concentration may be involved in the pathogenesis of fibromyalgia. Although the plasmatic level of calcium in fibromyalgia patients is always in the normal range, it seemed interesting to evaluate the intracellular calcium concentration.

The study was carried out on two groups of subjects: 70 affected by fibromyalgia and 40 healthy controls.

The results obtained show that in fibromyalgia patients the intracellular calcium concentration is significantly reduced in comparison to that of healthy controls: the reduced intracellular calcium concentration seems to be a peculiar characteristic of fibromyalgia patients and may be potentially responsible for muscular hypertonus.

The effective role of this anomaly in the physiopathology of fibromyalgia and the potential role of drugs active on the calcium homeostasis are still to be confirmed.

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Posted to Co-Cure Fri, 6 Jul 2001 22:59:12 -0400 by Fred Springfield

Evaluation of Clinical Physiotherapy on Fibromyalgia by Applying Methods Used in Research

Full Title: Evaluation of Clinical Physiotherapy on Fibromyalgia by Applying Methods Used in Research

Journal: J of Musculoskeletal Pain, Vol. 9(1) 2001, pp. 83-93

Author: Anne Marit Mengshoel, RPT, PhD

Affiliation: Center for Rheumatic Diseases, the National Hospital, Oslo, Norway.
Address correspondence to: Anne Marit Mengshoel, Department of Physiotherapy, the National Hospital, 0027 Oslo, Norway [E-mail: a.m.mengshoel@lab.med.uio.no].

Support was granted by the Norwegian Physiotherapy Association and Gjensidige Insurance Company.

Submitted: February 29, 2000.
Accepted without revision: May 31, 2000.

ABSTRACT.
Background: The measurement of the efficacy of physiotherapy often depends on retrospective evaluation. Prospective, repeated measurements by the Fibromyalgia Impact Questionnaire on a single patient showed how variables change in the course of a treatment process.

Findings: After an intervention period, the patient reported no change in health status when asked retrospectively. Compared with initial values the mean values for the second part of treatment showed a reduction in pain [66%], stiffness [70%], and physical impairment [42%].

Conclusion: Repeated measurements may show values for the size of treatment effects and their progression that the clinical observations do not detect.

KEYWORDS. Fibromyalgia, physiotherapy, nonmedical treatment, Fibromyalgia Impact Questionnaire, repeated measurements

INTRODUCTION
During the last few decades there has been an increasing demand for evaluation of the effects of physical therapy. This demand has major consequences for the practice and discipline of physiotherapy, since it means that attitudes toward treatment must be reviewed and methods developed to study established practices. The clinical effect of physiotherapy is usually expressed in terms of the patient's and the physiotherapist's retrospective evaluation. The validity of such information depends heavily on the patient's and the physiotherapist's memory of the situation prior to the treatment. In order to reduce such bias, the effect variables should be assessed before and after treatment. In order to obtain some idea of whether the changes are due to random variation or to the treatment itself, several assessments are needed. This type of design has been used for research purposes, and it was considered to be of interest to test whether it could be applied in a clinical setting as well. Conversely, accurate data from clinical situations may provide valuable information for research on the disease in question.

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com Web site: www.HaworthPress.com]

© 2001 by The Haworth Press, Inc. All rights reserved.

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Posted to Co-Cure Sat, 23 Jun 2001 15:17:44 -0400 by Fred Springfield

Visceral Hypersensitivity Is Not a Feature of Fibromyalgia Syndrome

Full Title: Visceral Hypersensitivity Is Not a Feature of Fibromyalgia Syndrome

Journal: J of Musculoskeletal Pain, Vol. 9(1) 2001, pp. 47-55

Authors: Fabio Pace, Piercarlo Sarzi-Puttini, Guendalina Manzionna, Paola Molteni, Maurizio Turiel, Benedetta Panni, Gabriele Bianchi-Porro

Affiliations: Fabio Pace, MD, Guendalina Manzionna, MD, Paola Molteni, MD, and Gabriele Bianchi-Porro, MD, are affiliated with the Gastroenterology Unit, University Hospital L. Sacco, v. G. B. Grassi 74, 20157 Milan, Italy.
Piercarlo Sarzi-Puttini, MD, and Benedetta Panni, MD, are affiliated with the Rheumatology Unit, University Hospital L. Sacco, Milan, Italy. Maurizio Turiel, MD, is affiliated with the Internal Medicine Division II, University Hospital L. Sacco, Milan, Italy.
Address correspondence to: Dr. Piercarlo Sarzi-Puttini, University Hospital L. Sacco, Rheumatology Unit, Via G. B. Grassi 74, 20157 Milan, Italy [E-mail address: Sarzi@tiscalinet.it].

Submitted: August 23, 1999.
Revision accepted: May 9, 2000.

ABSTRACT.
Objective: Visceral hyperalgesia is commonly observed in irritable bowel syndrome [IBS], a common cause of comorbidity with fibromyalgia syndrome [FMS]. The aim of this study was to evaluate in patients affected by FMS the presence of IBS-like symptoms and of visceral hyperalgesia.

Methods: Twenty-seven FMS patients were studied and compared with 32 IBS patients for visceral hyperalgesia by the anorectal balloon distension test.

Results: Eighteen [66%] of FMS patients fitted the Rome criteria for IBS. Patients with IBS presented lower than normal thresholds for the sensation of urgency and pain [P < 0.05], whereas the sensation of gas present in the rectum and of desire of defecation were not statistically different from normals. On the contrary, patients with FMS, either with or without IBS-like symptoms, presented values similar to normals for all the examined thresholds [P > 0.05].

Conclusions: Our study confirms that IBS symptoms are present in a relevant proportion of FMS patients, and that the majority of IBS patients present a condition of visceral hypersensitivity, as induced by a rectal balloon distension test. Patients with FMS, however, do not present this feature. The reason why FMS patients frequently have IBS-like symptoms with a normal visceral hypersensitivity remains elusive.

KEYWORDS. Fibromyalgia syndrome, irritable bowel syndrome, visceral hypersensitivity

INTRODUCTION
In recent years, it has become increasingly clear that visceral hyperalgesia (1) is a distinctive feature of the irritable bowel syndrome [IBS]. Fibromyalgia syndrome [FMS] is a chronic painful musculoskeletal syndrome (2,3), occurring in up to 2% of the general population, characterized by diffuse pain and tender points which shares many clinical and epidemiological features with IBS, such as, for example, the age [peak age of both conditions about 30-40 years], the gender [female are 80 to 90% of the patients] and associated conditions such as sleep disturbances, depression, and anxiety (4). The two conditions frequently coexist (5), with IBS described in 34-50% of cases (6-8); in addition, the presence of IBS is a minor criterion that has been proposed for the diagnosis of FMS (9). It has therefore been suggested that IBS and FMS may have a common pathogenetic mechanism (10, 11).

The aim of the present study has been to ascertain whether a condition of visceral hyperalgesia is present in patients with FMS as it is in IBS patients. For this purpose we have used the rectal balloon distension test, as previously described by Prior et al. (12).

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com Web site: www.HaworthPress.com]

© 2001 by The Haworth Press, Inc. All rights reserved.

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Posted to Co-Cure Mon, 25 Jun 2001 18:28:01 -0400 by Fred Springfield

Open Label Assessment of Botulinum Toxin A for Pain Treatment in a Private Outpatient Setting

Full Title: Open Label Assessment of Botulinum Toxin A for Pain Treatment in a Private Outpatient Setting

Journal: J of Musculoskeletal Pain, Vol. 9(1) 2001, pp. 67-82

Authors: Anthony H. Wheeler, MD and Paula Goolkasian, PhD

Affiliations: Anthony H. Wheeler, MD, is affiliated with the Charlotte Spine Center, Charlotte, NC.
Paula Goolkasian, PhD, is affiliated with the University of North Carolina at Charlotte, Department of Psychology, 9201 University City Boulevard, Charlotte, NC 28233-0001.
Address correspondence to: Anthony H. Wheeler, MD, Pain and Orthopedic Neurology, P.A., Charlotte Spine Center, 2001 Randolph Road, Charlotte, NC 28207.

Submitted: April 13, 2000.
Revision accepted: September 26, 2000.

ABSTRACT.
Objective: To determine efficacy and injection characteristics of botulinum toxin A [BTXA] treatment for refractory muscular pain in a private outpatient setting.

Methods: Medical records were analyzed retrospectively for a sample 44-patient cohort who received BTXA injections for refractory muscular pain between 1/1/96 and 12/31/98.

Results: Eighty percent of all patients reported reduced pain from the initial BTXA treatment. Thirty-two percent required one repeat injection and 27% received three or more.

Conclusion: These data suggest that BTXA may reduce focal muscular pain, and in many cases, the benefit outlasts the expected action of the toxin.

KEYWORDS. Myofascial pain syndrome, spinal pain, botulinum toxin, trigger point injections, therapeutic injections

INTRODUCTION
Spinal pain and disability are prevalent in industrialized societies (1). Mechanical pain syndromes of the spine are thought to be influenced by biomechanical factors, which affect injured or degenerative pain sensitive tissues that comprise the vertebral motion segment, including associated muscles (1). Characteristic changes in these muscles are often typical for a myofascial pain syndrome [MPS], which has defined diagnostic criteria (2). Myofascial pain syndrome consists of painful muscles which have increased tone and stiffness and contain trigger points [TrPs] which are tender, firm nodules, or taut bands, usually 3-6 mm in size (2). Palpation produces aching pain in localized reference zones (2). A localized muscle twitch can be produced by brisk transverse pressure or needling of the taut band (2). Trigger point palpation often elicits a "jump-sign," an involuntary reflex-like recoil or flinching by the patient, which is disproportionate to the pressure applied (2). The pathogenesis of myofascial TrPs is unknown; however, several hypotheses exist (3,4). Most recently, Simons combines growing electrophysiological and histopathological evidence for what he has aptly termed the "Integrated Trigger Point Hypothesis" (2). Abnormally increased production and excessive release of acetylcholine from the motor nerve terminal under resting conditions are hypothesized to initiate aberrant and sustained depolarization of the postjunctional membrane of the muscle fiber, thereby causing persistent muscle contraction which compresses local blood vessels and impairs arterial inflow, and with it the supply of oxygen and other nutrients necessary to meet the higher energy demands required by ongoing sarcomere shortening. Therefore, an intramuscular deficiency of energy occurs. Because muscle fiber relaxation also requires energy, which in this situation is not forthcoming, sustained contraction continues. In response to this pathologic state, neuroactive substances are released into the involved region, and local autonomic and sensory nerves become sensitized. These afferent influences also help drive ongoing excessive acetylcholine release at the neuromuscular junction, thereby, maintaining anomalous muscle contraction in a continuing reverberating cycle. This series of events has been postulated to result in extrafusal muscle contraction that forms a TrP. Furthermore, techniques that elongate the TrP portion of the muscle, even briefly, can reportedly break the cycle of energy consuming muscle contraction; therefore, blocking acetylcholine release at the neuromuscular junction may allow elongation of the [taut] TrP portion of the muscle and allow blood flow to be restored (2).

Botulinum toxin [BTX] is a potent neurotoxin with seven immunologically distinct serotypes, which are synthesized by the bacterium Clostridium botulinum. Botulinum toxin acts by blocking acetylcholine release at neuromuscular junctions (5,6). The seven serotypes and the bacteria which produces them are designated A, B, C, D, E, F, and G (7). Only A, B, and E have been linked to cases of botulism in humans (5). Currently, only botulinum toxin A [BTXA] is approved by the Food and Drug Administration [FDA] for the treatment of strabismus, blepharospasm, and seventh nerve disorders in patients 12 years or older (5). Clinical investigation supports the use of BTXA for the treatment of many focal dystonic and nondystonic disorders of muscle spasm that have not yet received FDA approval (5,6). Botulinum toxin A has also been demonstrated as an effective treatment for pain caused by conditions of muscle overactivity, such as dystonia and spasticity (8). Henceforth, research efforts are underway to demonstrate whether or not BTX can be applied to treat more common pain disorders such as headache, including migraine, and spine-related pain syndromes caused by associated muscle spasm or MPS (8-10).

Recently, some sufferers of refractory pain due to focal muscle spasm or MPS have been offered, and opted for, off-label use of BTXA as an adjunctive treatment for their condition. To study whether or not BTXA treatment was perceived as beneficial, the medical records of a sample population of private outpatients with chronic refractory myofascial pain or localized painful muscle spasm affecting the facial, cervicothoracic, and lumbosacral regions were extracted for analysis. This report describes injection characteristics and summarizes treatment outcomes for patients with muscular pain who were treated with BTXA.

[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com Web site: www.HaworthPress.com]

© 2001 by The Haworth Press, Inc. All rights reserved.

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