The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles

DESIGN: A randomized controlled trial.OB JECTIVE: To investigate the immediate effects on pressure pain thresholds over latent trigger points (TrPs) in the masseter and temporalis muscles and active mouth opening following atlanto-occipital joint thrust manipulation or a soft tissue manual intervention targeted to the suboccipital muscles. BACKGROUND : Previous studies have described hypoalgesic effects of neck manipulative interventions over TrPs in the cervical musculature. There is a lack of studies analyzing these mechanisms over TrPs of muscles innervated by the trigeminal nerve. METHODS: One hundred twenty-two volunteers, 31 men and 91 women, between the ages of 18 and 30 years, with latent TrPs in the masseter muscle, were randomly divided into 3 groups: a manipulative group who received an atlanto-occipital joint thrust, a soft tissue group who received an inhibition technique over the suboccipital muscles, and a control group who did not receive an intervention. Pressure pain thresholds over latent TrPs in the masseter and temporalis muscles, and active mouth opening were assessed pretreatment and 2 minutes posttreatment by a blinded assessor. Mixed-model analyses of variance (ANOVA) were used to examine the effects of interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model ANOVA revealed a significant group-by-time interaction for changes in pressure pain thresholds over masseter (P<.01) and temporalis (P =.003) muscle latent TrPs and also for active mouth opening (P<.001) in favor of the manipulative and soft tissue groups. Between-group effect sizes were small. CONCLUSIONS: The application of an atlanto-occipital thrust manipulation or soft tissue technique targeted to the suboccipital muscles led to an immediate increase in pressure pain thresholds over latent TrPs in the masseter and temporalis muscles and an increase in maximum active mouth opening. Nevertheless, the effects of both interventions were small and future studies are required to elucidate the clinical relevance of these changes. LEVEL OF EVIDENCE : Therapy, level 1b. J Orthop Sports Phys Ther 2010;40(5):310-317. doi:10.2519/jospt.2010.3257. KEYWORDSDS: cervical manipulation, muscle trigger points, neck, TMJ, upper cervical.

Efeito de diferentes substâncias na técnica de injeção em trigger points em pacientes portadores de dor miofascial e cefaléia crônica

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Síndrome Dolorosa Miofascial no contexto da Medicina Dentária

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Medicina Dentária

Distribution of terminal nerve entry points to the flexor and extensor groups of forearm muscles:An anatomical study

The motor points of the skeletal muscles, mainly of interest to anatomists and physiologists, have recently attracted much attention from researchers in the field of functional electrical stimulation. The muscle motor point has been defined as the entry point of the motor nerve branch into the epimysium of the muscle belly. Anatomists have pointed out that many muscles in the limbs have multiple motor points. Knowledge of the location of nerve branches and terminal nerve entry points facilitates the exact insertion and the suitable selection of the number of electrodes required for each muscle for functional electrical stimulation. The present work therefore aimed to describe the number, location, and distribution of motor points in the human forearm muscles to obtain optimal hand function in many clinical situations. Twenty three adult human cadaveric forearms were dissected. The numbers of primary nerves and motor points for each muscle were tabulated. The mean numbers and the standard deviation were calculated and grouped in tables. Data analyses were performed with the use of a statistical analysis package (SPSS 13.0). The proximal third of the muscle was the usual part of the muscle that received the motor points. Most of the forearm muscles were innervated from the lateral side and deep surface of the muscle. The information in this study may also be usefully applied in selective denervation procedures to balance muscles in spastic upper limbs. Copyright © 2007 Via Medica.

Efeito imediato da técnica músculo energia do esternocleidomastóideo com ponto gatilho latente na sensibilidade dolorosa à pressão e nas amplitudes cervicais

Introdução: Os pontos gatilho (PG) do esternocleidomastóideo (ECM) podem ser a causa de dor na face e no crânio. A técnica músculo-energia (TME) pode ser utilizada na presença de PG. Objectivo: Verificar qual o efeito imediato da TME, aplicada no ECM, na sensibilidade dolorosa à pressão (SDP) do PG do ECM e nas amplitudes cervicais em comparação com uma técnica placebo. Metodologia: Uma amostra voluntária de 52 indivíduos foi dividida aleatoriamente por dois grupos. Inicialmente foi medida a SDP e as amplitudes dos movimentos activos da coluna cervical. Após a aplicação da TME, com 20% da força máxima, e da técnica placebo, nos respectivos grupos, a SDP e as amplitudes cervicais foram reavaliadas. Resultados: Não existiram diferenças estatísticas significativas para afirmar que os dados recolhidos antes e depois da aplicação da TME eram significativamente diferentes. Conclusão: Os efeitos imediatos da TME, neste estudo, não foram significativos. No entanto, a bibliografia aponta noutro sentido, tornando-se importante perceber de que forma podemos melhorar a aplicação da TME, de forma a optimizar os seus efeitos.

O efeito da técnica de inibição de Jones nos músculos Masseter e temporal nas disfunções temporomandibulares

Introdução: A disfunção temporomandibular (DTM), de causa muscular, caracteriza-se por uma dor músculo-esquelética crónica, com sinais e sintomas específicos como a presença de Trigger Points (TrPs). Objetivo: Avaliar o efeito da Técnica de Inibição de Jones (TIJ) nos músculos masseter e temporal em indivíduos com DTM, e a identificação dos sinais e sintomas, a relação entre a severidade da DTM, a ansiedade e a qualidade de sono. Métodos: Estudo quasi-experimental, constituído por 16 indivíduos no grupo experimental (GE) e 17 grupo controle (GC). O grau de severidade foi avaliado pelo Índice de Helkimo e as alterações do sono pelo questionário de Pittsburgh sobre a qualidade do sono. Apenas o GE foi sujeito a uma TIJ nos TrPs latentes dos músculos masseter e temporal. Os dois grupos foram avaliados pré-intervenção (M0), pós-intervenção (M1) e 3 semanas após (M2), as amplitudes de movimento ativas de abertura, lateralidade direita/esquerda e protusão da boca bem como a dor (EVA) em repouso e na abertura máxima. Resultados: Foi possível observar que quanto maior o grau de DTM, maior a frequência de ansiedade e pior a qualidade do sono. Observou-se um decréscimo de TrPs, no GE, após a aplicação da técnica, principalmente no masseter. Não foi possível verificar diferenças inter-grupos. Contudo, observou-se no GE uma melhoria em todas as amplitudes avaliadas entre o M0 e o M2. Em relação à EVA em repouso e na abertura máxima, o GE demonstrou diminuição da dor no M1 e manteve valores inferiores no M2. Conclusão: Verifica-se uma diminuição dos TrPs, uma melhoria das amplitudes ativas bem como uma diminuição da dor após a aplicação da TIJ no GE. Já ao longo do tempo, o efeito é menos expressivo contudo observam-se valores inferiores comparativamente a M0.

Efeito da compressão isquémica no ponto gatilho latente do trapézio superior, na magnitude de atividade muscular do complexo articular do ombro

Introdução: A síndrome dolorosa miofascial é um dos principais problemas encontrados na prática clínica, tendo como principais características os pontos gatilho (PG), ativos ou latentes. Os PG latentes têm uma elevada prevalência na musculatura da cintura escapular, nomeadamente ao nível do trapézio superior (TS), influenciando o controlo motor do ombro. A compressão isquémica aplicada no PG do TS poderá influenciar o comportamento muscular dos sinergistas durante o movimento de abdução no plano da omoplata. Objetivos: Este estudo visa estudar a influência da compressão isquémica aplicada no PG do TS na magnitude de ativação dos músculos TS, trapézio inferior (TI), grande dentado (GD), infra-espinhoso (IE) e deltóide médio (DM), assim como a relação muscular através da razão entre o TS e os restantes músculos em análise, durante o movimento de abdução no plano da omoplata. Métodos: O presente estudo é experimental, aleatório e controlado. Foram criados dois grupos, grupo controlo (GC) (n=14) e grupo experimental (GE) (n=15), a partir de uma amostra de 67 indivíduos. No GC foi aplicado um procedimento placebo e no GE foi aplicada no PG latente do TS a técnica de compressão isquémica. Antes e após a intervenção foi recolhida a atividade eletromiográfica dos músculos em análise, assim como os dados cinemáticos, durante o movimento de elevação do ombro no plano da omoplata. Para a análise registou-se a amplitude máxima de abdução e foi analisada a atividade muscular individual dos músculos em estudo assim como a razão entre o TS e os restantes músculos. Esta análise foi realizada em intervalos de 30° até ao final do movimento. Resultados: Não se verificaram diferenças na amplitude máxima de abdução, nem entre grupos (1º momento p=0,608, t=0,816; 2º momento p=0,119; t=1,252) nem entre os dois momentos em cada grupo (GC, t=-1,119; p=0,256; GE, t=-1,604, p=0,135). Na magnitude de ativação individual de cada músculo também não se verificaram diferenças significativas com a aplicação da técnica, tendo-se verificado no DM uma tendência para o aumento da ativação aquando da intervenção, ao longo de todo o arco de movimento, em comparação com a pré-intervenção, já no GC de controlo não se verificaram alterações entre momentos. Também na análise da razão entre músculos não se verificaram diferenças entre grupos. Conclusão: A intervenção realizada não influenciou nenhum dos parâmetros em análise do complexo articular do ombro nem a amplitude de movimento de abdução.

Myofascial Pain Syndrome as a Contributing Factor in Patients with Chronic Headaches

Objectives: The purpose of this study was to evaluate the prevalence of active and latent trigger points [TrPs], as well as analyze the prevalence of different types of headaches in chronic headache patients. The active and latent TrPs in muscles of orofacial and cervical regions were also evaluated. Methods: There were 290 subjects who participated in this study. Trigger points were identified according to Simons et al.'s diagnostic criteria. Trigger points were considered active if subjects recognized the evoked referred pain as their familiar headache. If the evoked referred pain was not recognized as the familiar headache, the TrPs were considered latent. Differential diagnosis for headache was performed on the basis of International Headache Society criteria. Results: Trigger points could be diagnosed in 77 percent of patients and, in 89 percent of these, active TrPs were found. Muscle tenderness could be observed in 22 percent of patients, and only 1 percent patients were muscle-pain-free. The headache diagnosis showed that 26 percent had tension-type headache, 13 percent had migraine, and 61 percent had combined episodes of tension-type headache and migraine. The highest number of TrPs were found in temporalis [N = 159], masseter [N = 126], and occiptofrontalis [N = 113] muscles. Active TrPs were more frequent in temporalis and occiptofrontalis muscles. Conclusions: Subjects with chronic headaches had a higher prevalence of TrPs, and headache complaints could be reproduced during stimulation of active TrPs that were localized more frequently in temporalis and occiptofrontalis muscles. The presence of TrPs may be a contributing factor in the initiation and/or perpetuation of chronic headaches.

Acupuntura e implante de fragmentos de ouro em pontos de acupuntura e pontos Acupuntura e implante de fragmentos de ouro em pontos de acupuntura e pontos gatilho para o tratamento de displasia coxo-femoral em Pastor Alemão

Background: Canine hip dysplasia (HD) is characterized by hip joint laxity and subluxation. It is the most common cause of osteoarthritis in dogs, especially in larger breeds. Its management includes nutritional supplements, nonsteroidal anti-inflammatory drugs, physical therapy, acupuncture or surgical procedures. Implantation of gold beads in acupuncture points and trigger points around a joint has been used in the treatment of osteoarthritis in dogs for at least 30 years. Gold bead implants(GBI) acts as continuous acupuncture stimulation and trigger point treatment in canine HD with long lasting results. Electrophysiological investigations of trigger points reveal dysfunctional muscle spindles which indicate that the electrical activity of active loci arises from extrafusal motor endplates.Case: This is a report on the use of acupuncture and GBI for bilateral HD in a nine year old female German Shepherd. The patient has a HD non-responsive to anti-inflammatory drugs and was unable to stand up or walk by its own. Radiographs showed marked dysplasia, significant subluxation with the femoral head partly out of a shallow acetabulum and massive secondary arthritic bone changes, mainly on the right side. The animal was submitted to eight acupuncture sessions with seven days interval. After the first acupuncture session the use of NSAID was interrupted. After eight weeks the dog was considered rehabilitated and underwent GBI in acupoints and trigger points as maintenance treatment. During the one-year follow-up period the improvement remained unchanged with no need of analgesics.Discussion: It has been suggested that acupuncture or GBI can treat the chronic pain resulting from osteoarthritis induced by HD. According to AP theory, GBI is permanent and long-lasting acupoint stimulation. Moreover, the method is inexpensive, quick and easy to perform, with no postoperative pain or need of exercise restriction. Although gold is extremely corrosion-resistant, the surface of the gold implants stimulates a reaction from the immune system causing an oxidative liberation of gold ions with anti-inflammatory actions. It is well known that gold ions are effective inhibitors of the respiratory burst of neutrophils and monocytes and the proliferation of lymphocytes. These findings suggest that gold implantation, on a local scale, mimics the anti-inflammatory and pain-relieving effect of drugs with chemically bound gold ions. The relatively slow speed of the process results in a limited liberation of gold ions securing that they are taken up almost exclusively by cells close to the implant. The nine year old female German shepherd had a positive response to acupuncture with pain relieve and locomotor rehabilitation. For the nine year old female German shepherd previous acupuncture sessions to GBI resulted in no post-implant worsening period. Indeed, the association acupuncture/GBI does not have the anti-inflammatory drugs undesirable effects and brings long lasting results. In conclusion, GBI therefore should be considered for canine HD when conservative or medical treatments fail to give the desired effect.

Correspondence of the auricular acupoint with the upper trapezius muscle: A electromyographic study

Presently, acupuncture is a technique considered to be capable of stimulating the regulatory systems of the organism, such as the central nervous system, the endocrine system and the immunological system. The median frequency of the upper trapezium muscle with 40% and 60% of maximal voluntary contraction (MVC) of 15 healthy volunteers, was analyzed after the individuals were submitted to the AA treatment. The non-parametric Friedman test was used to compare median frequency values. In this exploratory study, the level of significance of each comparison was set to p < 0.05. The intraclass analyses indicate a significant increase of the median frequency muscle at 60% of the MVC (Wicoxon test). Based on the results found, the AA peripheral stimulus can act as a modulator mechanism of muscle activity and was possible to verify correspondence of the auricular acupoint with the trapezius muscle. © 2009 Elsevier Ltd. All rights reserved.

Research data finder : an institutional metadata repository

QUT’s new metadata repository (data registry), Research Data Finder, has been designed to promote the visibility and discoverability of QUT research datasets. Funded by the Australian National Data Service (ANDS), it will provide a qualitative snapshot of research data outputs created or collected by members of the QUT research community that are available via open or mediated access. As a fully integrated metadata repository Research Data Finder aligns with institutional sources of truth, such as QUT’s research administrative system, ResearchMaster, as well as QUT’s Academic Profiles system to provide high quality data descriptions that increase awareness of, and access to, shareable research data. In addition, the repository and its workflows are designed to foster smoother data management practices, enhance opportunities for collaboration and research, promote cross-disciplinary research and maximize existing research datasets. The metadata schema used in Research Data Finder is the Registry Interchange Format - Collections and Services (RIF-CS), developed by ANDS in 2009. This comprehensive schema is potentially complex for researchers; unlike metadata for publications, which are often made publicly available with the official publication, metadata for datasets are not typically available and need to be created. Research Data Finder uses a hybrid self-deposit and mediated deposit system. In addition to automated ingests from ResearchMaster (research project information) and Academic Profiles system (researcher information), shareable data is identified at a number of key “trigger points” in the research cycle. These include: research grant proposals; ethics applications; Data Management Plans; Liaison Librarian data interviews; and thesis submissions. These ingested records can be supplemented with related metadata including links to related publications, such as those in QUT ePrints. Records deposited in Research Data Finder are harvested by ANDS and made available to a national and international audience via Research Data Australia, ANDS’ discovery service for Australian research data. Researcher and research group metadata records are also harvested by the National Library of Australia (NLA) and these records are then published in Trove (the NLA’s digital information portal). By contributing records to the national infrastructure, QUT data will become more visible. Within Australia and internationally, many funding bodies have already mandated the open access of publications produced from publicly funded research projects, such as those supported by the Australian Research Council (ARC), or the National Health and Medical Research Council (NHMRC). QUT will be well placed to respond to the rapidly evolving climate of research data management. This project is supported by the Australian National Data Service (ANDS). ANDS is supported by the Australian Government through the National Collaborative Research Infrastructure Strategy Program and the Education Investment Fund (EIF) Super Science Initiative.

An approach for identifying the limit states of resilience of a water supply system

This paper presents an approach for identifying the limit states of resilience in a water supply system when influenced by different types of pressure (disturbing) forces. Understanding of systemic resilience facilitates identification of the trigger points for early managerial action to avoid further loss of ability to provide satisfactory service availability when the ability to supply water is under pressure. The approach proposed here is to illustrate the usefulness of a surrogate measure of resilience depicted in a three dimensional space encompassing independent pressure factors. That enables visualisation of the transition of the system-state (resilience) between high to low resilience regions and acts as an early warning trigger for decision-making. The necessity of a surrogate measure arises as a means of linking resilience to the identified pressures as resilience cannot be measured directly. The basis for identifying the resilience surrogate and exploring the interconnected relationships within the complete system, is derived from a meta-system model consisting of three nested sub-systems representing the water catchment and reservoir; treatment plant; and the distribution system and end-users. This approach can be used as a framework for assessing levels of resilience in different infrastructure systems by identifying a surrogate measure and its relationship to relevant pressures acting on the system.

Resilience of water supply systems in meeting the challenges posed by climate change and population growth

This research project provides a scientifically robust approach for assessing the resilience of water supply systems, which are critical infrastructure, to impacts of climate change and population growth. An approach for the identification of trigger points that allows timely and appropriate management actions to be taken to avoid catastrophic system failure is an important outcome of this project. In the current absence of a formal method to evaluate the resilience of a water supply system, the approach developed in this study was based on the characterisation of resilience of a water supply system to a range of surrogate measures. Accordingly, a set of indicators are proposed to evaluate system behaviour and logistic regression analysis was used to assess system behaviour under predicted rainfall, storage and demand conditions.

Extended histories: improving regularity and performance in correlation prefetchers

Data Prefetchers identify and make use of any regularity present in the history/training stream to predict future references and prefetch them into the cache. The training information used is typically the primary misses seen at a particular cache level, which is a filtered version of the accesses seen by the cache. In this work we demonstrate that extending the training information to include secondary misses and hits along with primary misses helps improve the performance of prefetchers. In addition to empirical evaluation, we use the information theoretic metric entropy, to quantify the regularity present in extended histories. Entropy measurements indicate that extended histories are more regular than the default primary miss only training stream. Entropy measurements also help corroborate our empirical findings. With extended histories, further benefits can be achieved by triggering prefetches during secondary misses also. In this paper we explore the design space of extended prefetch histories and alternative prefetch trigger points for delta correlation prefetchers. We observe that different prefetch schemes benefit to a different extent with extended histories and alternative trigger points. Also the best performing design point varies on a per-benchmark basis. To meet these requirements, we propose a simple adaptive scheme that identifies the best performing design point for a benchmark-prefetcher combination at runtime. In SPEC2000 benchmarks, using all the L2 accesses as history for prefetcher improves the performance in terms of both IPC and misses reduced over techniques that use only primary misses as history. The adaptive scheme improves the performance of CZone prefetcher over Baseline by 4.6% on an average. These performance gains are accompanied by a moderate reduction in the memory traffic requirements.

The Management of Long-Term Sickness Absence in Large Public Sector Healthcare Organisations: A Realist Evaluation Using Mixed Methods

Purpose The success of measures to reduce long-term sickness absence (LTSA) in public sector organisations is contingent on organisational context. This realist evaluation investigates how interventions interact with context to influence successful management of LTSA. Methods Multi-method case study in three Health and Social Care Trusts in Northern Ireland comprising realist literature review, semi-structured interviews (61 participants), Process-Mapping and feedback meetings (59 participants), observation of training, analysis of documents. Results Important activities included early intervention; workplace-based occupational rehabilitation; robust sickness absence policies with clear trigger points for action. Used appropriately, in a context of good interpersonal and interdepartmental communication and shared goals, these are able to increase the motivation of staff to return to work. Line managers are encouraged to take a proactive approach when senior managers provide support and accountability. Hindering factors: delayed intervention; inconsistent implementation of policy and procedure; lack of resources; organisational complexity; stakeholders misunderstanding each other’s goals and motives. Conclusions Different mechanisms have the potential to encourage common motivations for earlier return from LTSA, such as employees feeling that they have the support of their line manager to return to work and having the confidence to do so. Line managers’ proactively engage when they have confidence in the support of seniors and in their own ability to address LTSA. Fostering these motivations calls for a thoughtful, diagnostic process, taking into account the contextual factors (and whether they can be modified) and considering how a given intervention can be used to trigger the appropriate mechanisms.