Human T-lymphotropic virus 1 (HTLV-1) infection has been associated with inflammatory, autoimmune, and lymphoproliferative diseases with a wide spectrum of clinical manifestations. Among patients with inflammatory rheumatological disease manifestations, cases of rheumatoid arthritis, Sjögren’s syndrome, polymyositis, and fibromyalgia, among others, have been reported. Another common feature of rheumatological diseases is the presence of joint manifestations, such as arthralgia and arthritis. In the present study, we sought to determine the laboratory profile and clinical rheumatological manifestations of people living with HTLV-1/2 residing in a metropolitan area in the Brazilian Amazon. A total of 957 individuals were screened for HTLV-1/2 infection by enzyme-linked immunosorbent assay (ELISA), and samples from seropositive individuals were subjected to infection confirmation by Western blotting or quantitative polymerase chain reaction (qPCR). Individuals with confirmed HTLV-1 and HTLV-2 infection were clinically evaluated for signs and symptoms of rheumatological diseases. Of the 957 individuals tested, 69 were positive for HTLV-1/2 infection, with 56 confirmed cases of HTLV-1 infection (5.9%), 12 of HTLV-2 infection (1.2%), and 1 classified as undetermined (0.1%). After clinical screening, 15 infected individuals with complaints suggestive of rheumatological disease were selected for evaluation by a rheumatologist (11 with HTLV-1 infection (1.1%) and 4 with HTLV-2 infection (0.4%)). The predominant pain pattern was symmetrical polyarthralgia, with large joints predominantly being affected. The diseases diagnosed were psoriatic arthritis, osteoarthritis, fibromyalgia, and regional pain syndromes. Antinuclear antibody (ANA) positivity was observed in two patients. Our findings confirm that HTLV-1 infection is associated with rheumatological disease manifestations and highlight the novel finding of cases of HTLV-2 infection in patients with rheumatoid arthritis symptoms.

Family physicians and sports medicine practitioners frequently encounter patients with musculoskeletal (MSK) pain that does not conform to specific diagnostic patterns. One potential explanation for such ambiguous pain syndromes is soft tissue injury, including fascial damage, which may not yet be detectable on imaging studies. The fascial system (FS) is an intricate network comprising both superficial and deep layers. Over the last decade, its dysfunction has been increasingly linked to MSK disorders and regional pain syndromes [1-3]. As a biomechanical structure and a major sensory organ, the FS houses numerous sensory receptors, making it crucial for both structural integrity and sensory modulation [4, 5]. Glucopuncture (GP) involves the administration of 5% glucose (G5W) or 5% dextrose (D5W or D-glucose) injections into fascia, muscles, ligaments, or joints. Particularly multiple superficial fascia injections have gained popularity as a treatment for poorly localized pain syndromes [6-8]. This article describes the case of a 75-year-old woman with a three-month history of pain in her left knee fold, successfully managed with palpation-guided GP. Interestingly, in this case, the injections targeted trigger points that are distant from the pain region, illustrating the potential for this method to address referred pain caused by superficial fascial dysfunction. GP represents an accessible, cost-effective, and eco-friendly approach for clinicians with limited access to advanced imaging or ultrasound. Further research is needed to confirm its efficacy and safety in treating vague MSK pain [9, 10].

Abstract Background Shoulder internal rotation contracture, active abduction and external rotation deficits are frequent secondary complications observed in children with obstetric brachial plexus palsy (OBPP). Soft tissue shoulder operations are often done for treatment as arthroscopic capsular release and open subscapularis recession. There is a lack of studies regarding the subscapularis recession and also regarding the comparison between the two techniques. Aim of the Work to review systematically and meta-analyze the currently available literature regarding arthroscopic capsular release (ACR) and open subscapularis recession (OSR) in internal shoulder contracture in OBPP regarding the clinical efficacy and complications. Methods A literature search pooled the studies pertaining to the children with OBPP in early age treated with ACR and OSR. A systematic review and meta-analysis was conducted to assess the success rates of the two techniques using the Mallet score. We excluded the studies or the patients with history of any concomitant surgical interventions eg: humeral osteotomy, tendon transfer. Results Data from eight studies (152 patients) were compiled for our meta-analysis. The mean follow-up duration was 23.87 months with average age 2.4 years. The standardized difference in means (SMD) for the active abduction (ABD. score was 0.59 for the ACR in comparison to the OSR (SMD= 0.427). The Std. diff. regarding the ACR was 1.22 in passive abduction, 1.68 in passive external rotation (ER) in ABD., 2.31 in passive ER in adduction, 2.38 in hand to mouth, 2.67 in hand to neck, -0.49 in hand to spine, 2.84 in total Mallet score, 3.18 in the active ER (in comparison to the OSR the SMD was 0.427) and -2.06 in active internal rotation (in comparison to the OSR the SMD was 0.128). Recurrence of internal shoulder contracture was documented in 8 of 93 children after ACR and regional pain syndrome with shoulder stiffness was reported in only on case out of 28 cases after ACR. Conclusion In this study, we found that the ACR is highly effective than the OSR technique regarding the functional outcome of the shoulder in all the Mallet score items except in hand to spine and internal rotation. The ACR shows more advantages than OSR intra-operatively regarding soft tissue identification and post-operatively regarding scarring and infection, but with higher risk of recurrence and axillary nerve injury.

The third most common musculoskeletal disorder is fibromyalgia, which becomes more common as people age. The most common symptoms of fibromyalgia are tiredness, sleep difficulties, persistent pain throughout the body, and functional problems. Etiopathogenesis, diagnostic standards, and classification criteria of this disorder are still up for debate. Despite the development of more reliable diagnostic criteria, a significant proportion of physicians continue to misdiagnose the illness. Familial experiences, emotional-cognitive factors, the mind-body connection, genetic predisposition, and a biopsychological capacity for stress management are some of the numerous variables that each individually contribute to the development of fibromyalgia. In this review, we present a comprehensive, critical assessment of fibromyalgia's burden and diagnosis, taking into account the most recent research, recommendations, and clinical experience. By utilizing clinical expertise and the most recent EULAR criteria for managing fibromyalgia, we want to offer doctors an innovative and useful management workflow that they may utilize in their routine clinical duties. Keywords: fibromyalgia, chronic pain, sleep disturbances, fatigue, autonomic disturbances, regional pain syndromes, tender points.

Abstract Background/Aims Autoimmune rheumatic diseases are frequently diagnosed in women of childbearing age. Managing these conditions during pregnancy is complex because commonly used disease-modifying antirheumatic drugs (DMARDs) can pose risks. Specialized care for this patient group is crucial, necessitating adherence to established rheumatology practice standards and British Society for Rheumatology (BSR) guidelines. Our main objective is to review management of childbearing age females with rheumatic diseases attending Basildon hospital as per BSR guidelines. Methods The data for this retrospective study was collected from the electronic records of female patients attending the rheumatology outpatient clinic at Basildon Hospital between September and December 2022. We reviewed age, the specific rheumatological diagnosis, disease duration, disease activity, current medications, and whether general advice or pregnancy-specific advice was provided. Results Out of the initial cohort of 63 female patients, 48 (76%) aged between 18-55 years were selected as women of childbearing age, The median age was 46 years, with 65% in the age groups of 31-50 years, 25% in group 51-55 years and 10% 18-30 years age group. 58% of patients had inflammatory arthritis, 18.7% had connective tissue disease, 18.7% had other conditions such as hypermobility, osteoarthritis, and regional pain syndrome, 2.3% were diagnosed with vasculitis and 2.3% with polymyalgia rheumatica. Breakdown of inflammatory arthritis patients revealed rheumatoid arthritis in 64%, psoriatic arthritis 15% and ankylosing spondylitis 12%. Axial spondyloarthropathy, palindromic rheumatism, and juvenile idiopathic arthritis, each accounted for 3%. Regarding prescribed medications, 66% of the individuals were on conventional DMARDs, biologics 24%, corticosteroids 6% and 4% were on other treatments. The DMARDs prescribed were methotrexate 27%, hydroxychloroquine 19%, sulfasalazine 13%, mycophenolate 3% and leflunomide 1%. The majority of patients had disease activity in remission or mild, each accounting for 23%. Moderate and severe disease activity were reported in 21% each of the audited sample. Patients received advice specifically related to pregnancy 29%, while 71% did not have documented pregnancy-related guidance. 70% of females of reproductive age received general advice. Conclusion The study highlights a gap in pregnancy-related advice among the childbearing age patients as only 29% received guidance on pregnancy. This underpins the need for proactive counselling and education for female patients in routine practice, work in partnership with obstetric teams, and primary care to reduce potential pregnancy related complications and improve outcomes. Disclosure M. Mohareb: None. S. Ahmed: None. A. Bharadwaj: None. A. Nandagudi: None.

The causes of ACL reconstruction (ACLR) failure can be divided into 3 majorcategories. Non-anatomic tunnel placement has been the most widely statedtechnical error in ACL repair. A thorough medical history is necessary andcrucial to determine the likely cause of failure in the initial surgery. Assuch, the medical history and physical examination should be evaluated. Inaddition, physical examination of the knee should be performed such as alignmentof lower extremities, existence of varus and or valgus deformity, presence ofcontractures in flexion or extension and special tests to evaluate ACL.Moreover, imaging by radiography which includes anteroposterior, lateral,Merchant and Rosenberg views must be consider evaluating. Failure of an ACLR maynot necessarily need revision surgery. Patients with bi/tri-compartmentalarthritis or regional pain syndromes, those without recurring instability, thosewho live a sedentary lifestyle, or those who refuse to participate inpost-operative rehabilitation may not be ideal candidates for revision ACLR.Patients with a failed ACL reconstruction commonly presenting with sign andsymptoms of instability, stiffness, and pain. The choice of graft is critical toprocedure’s success. In the revision setting, fixation is just as critical asgraft selection. The aim of the revision surgery is to stabilize the knee joint,prevent further damage to the cartilage and the menisci, and allow the patientto resume normal daily and/or sports activities. A successful revision surgeryrequires accurate preoperative patient evaluation and knee imaging.

Myofascial pain syndrome (MPS) is a regional pain syndrome that causes pain due to hyperirritable trigger points in the musculoskeletal system. Trapezius is one of the most commonly affected muscles in MPS. We aimed to evaluate the efficacy of an ultrasound-guided interfascial block of the trapezius muscle in patients with MPS. The records of patients who underwent an ultrasound-guided interfascial block of the trapezius between November 2019 and October 2020 were retrospectively examined. The pain levels of the patients were evaluated with the numeric rating scale (NRS). Patients with a reduction in pain ≥50% after the procedure were considered to have benefited from the procedure. A total of 54 patients (41 women and 13 men) were evaluated. The mean NRS values of the patients were 7.16 (5-9) before the procedure, 3.31 (0-8) 10 min after the procedure, and 3.37 (0-8) 1 week after the procedure. The number of patients who benefited from the procedure was 40 (74.07%) 10 min after the procedure. The number of patients who benefited from the procedure for up to 1 week, 1-2 weeks, 2 weeks-1 month, 1-3 months, and more than 3 months after the procedure was 38 (70.37%), 36 (66.66%), 31 (57.40%), 26 (48.14%), and 17 (31.48%), respectively. Pain relief lasting for months was achieved in most of the patients. We believe that ultrasound-guided interfascial block of the trapezius is effective for the treatment of MPS.

Background: Naltrexone is an opioid receptor antagonist commonly used to treat opioid and alcohol dependence. The use of low dose naltrexone (LDN) was found to have anti-inflammatory properties for treatment of diseases such as fibromyalgia, Crohn’s disease, multiple sclerosis and regional pain syndromes. Related to its anti-neuroinflammatory properties, the mechanism of action is possibly mediated via Toll-like receptor 4 antagonism, which is widely expressed on microglial cells. The aim of the present study was to assess the immunometabolic effects of naltrexone on microglia cells in in vitro conditions. Methods: All experiments were performed in the BV-2 microglial cell line. The cells were treated with naltrexone at 100 μM concentrations corresponding to low dose for 24 h. Cell viability was assessed for every drug dose. To induce additional activation, the cells were pretreated with LPS and IFN-γ. Immunofluorescence was used to analyse the classical microglial activation markers iNOS and CD206, while Seahorse was used for real-time cellular metabolic assessments. mTOR activity measured over the expression of a major direct downstream target S6K was assessed using western blot. Results: LDN induced a shift from highly activated pro-inflammatory phenotype (iNOShighCD206low) to quiescent anti-inflammatory M2 phenotype (iNOSlowCD206high) in BV-2 microglia cells. Changes in the inflammatory profile were accompanied by cellular metabolic switching based on the transition from high glycolysis to mitochondrial oxidative phosphorylation (OXPHOS). LDN-treated cells were able to maintain a metabolically suppressive phenotype by supporting OXPHOS with high oxygen consumption, and also maintain a lower energetic state due to lower lactate production. The metabolic shift induced by transition from glycolysis to mitochondrial oxidative metabolism was more prominent in cells pretreated with immunometabolic modulators such as LPS and IFN-γ. In a dose-dependent manner, naltrexone also modulated mTOR/S6K expression, which underlies the cell metabolic phenotype regulating microglia immune properties and adaptation. Conclusion: By modulating the phenotypic features by metabolic switching of activated microglia, naltrexone was found to be an effective and powerful tool for immunometabolic reprogramming and could be a promising novel treatment for various neuroinflammatory conditions.

Myofascial pain syndrome (MFPS) is a regional pain syndrome that can be diagnosed in any age group and is characterized by the presence of a trigger point in the muscle involved in the pathological process. Clarifying the molecular mechanisms of trigger point formation and dysregulation of specific skeletal muscle proteins is important to understand the causes of abnormal sarcomere contraction observed in myofascial pain. Wide variability in using the diagnostic criteria in some cases leads to the impossibility of performing a meta-analysis of the data; in this connection, the search for the gold standard for MFPS diagnosis is actively underway. At the moment, a special clinical examination is of paramount diagnostic value. The paper considers various treatment options for myofascial pain and discusses the priority importance of using nonsteroidal anti-inflammatory drugs and muscle relaxants, as well as non-drug therapies.

Back to the roots of rheumatology - Imaging of regional pain syndromes.

Background: Neuropathic pain is a complex condition that is difficult to control and has a high impact on quality of life. 8% Capsaicin patch can be a therapeutic strategy in the treatment of peripheral neuropathic pain. Objectives: This study aims to (1) evaluate clinical efficacy and (2) tolerability of 8% capsaicin patch in a Pain Unit. Study Design: Retrospective observational study Setting: Portuguese Pain Unit Methods: A sample of 120 patients diagnosed with peripheral neuropathic pain, underwent treatment with the 8% capsaicin patch between February 2011 and February 2019 in a Portuguese Pain Unit. Patients were included in one of the following groups according to the etiology of pain: postherpetic neuralgia (PHN), chronic post-surgical pain (CPSP), post traumatic neuropathic pain (PTNP), diabetic neuropathy (DN), regional pain syndrome. complex I and II (CRPS I / II), HIVassociated neuropathy (HIVN), lumbar neuropathic pain (LNP), trigeminal neuralgia (TN) and other neuropathies (O). The evaluated parameters were: pain intensity according to unit protocol (numerical rating scale), pain characteristics, location, size of the painful area. The evolution of pain intensity after treatment (patients were considered as responders to therapy if the decrease in NRS was equal to or greater than 30%; patients with a decrease in NRS of 50% or more were also analyzed), the area of pain and the need for adjuvant analgesic therapy, as well as the tolerability to treatment and the identification of eventual predictors of its efficacy were evaluated, at 15 days, 8 weeks and 12 weeks after 8% capsaicin patch. Results: Of the 120 patients in the sample, 40.8% had a ≥ 30% decrease in basal pain intensity 15 days after treatment, 43.3% after 8 weeks and 45.0% after 12 weeks. 30.8% of patients had ≥ 50% decreased basal pain intensity 15 days after treatment, 27.5% after 8 weeks and 30.0% after 12 weeks. Pain area decreased in 36.7% of patients and 18.3% reduced chronic analgesic therapy within 12 weeks after 8% capsaicin patch application. There was only one case of intolerance to the treatment. Limitations: This study has the limitations inherent to a retrospective study. The study period was only 12 weeks and some diagnostic groups included a small number of patients. Conclusion: Treatment of peripheral neuropathic pain with 8% capsaicin patch seem to be effective in the short and medium term, both in decreasing pain intensity and in reducing the painful area. Its application is tolerated by most patients. Key words: 8% capsaicin patch, peripheral neuropathic pain, pain intensity, painful area

The developments in technology have improved access to the use of musculoskeletal ultrasound (MSUS) in different clinical settings. Accordingly, MSUS has been applied to a wide range of musculoskeletal problems including inflammatory and degenerative diseases, sport injuries, and regional pain syndromes both for clinical practice and research. In this report, the authors aimed to globally examine the publications on MSUS among different specialties, countries, and topics. Sixteen reviewers under the umbrella of the European Musculoskeletal Ultrasonography Society Group and the Ultrasound Study Group of International Society of Physical and Rehabilitation Medicine have evaluated approximately 15,000 publications on MSUS. The authors believe that the results of this comparative analysis may provide a holistic snapshot with regard to the utility of MSUS, not only for clinicians/academicians but also for the industry. Accordingly, while aiming to further increase their awareness, this article would possibly guide future investments as well.

We have utilized relative motion splinting for early motion following acute repair of boutonniere injuries, and we have developed nonoperative orthosis-based therapy for the treatment of chronic injuries. We offer our early clinical experience using relative motion flexion splinting for boutonniere deformities and explain the anatomic rationale that permits immediate active motion and hand use following acute injury or repair. For chronic boutonniere deformity, we offer a nonsurgical management method with low morbidity as a safe alternative to surgery. Our understanding of the extrinsic-intrinsic anatomic interrelationship in boutonniere deformity offers rationale for relative motion flexion splinting, which is confirmed by cadaver study. Our early clinical results in 5 closed and 3 open acute and 15 chronic cases have encouraged recommending this management technique. For repaired open and closed acutely injured digits, we utilize relative motion flexion orthoses that place the injured digits in 15° to 20° greater metacarpophalangeal flexion than its neighboring digits and otherwise permit full active range of motion and functional hand use maintaining the 15° to 20° greater metacarpophalangeal flexion for 6 weeks. In fixed chronic boutonniere cases, serial casting is utilized to obtain as much proximal interphalangeal extension as possible (at least -20°), and then relative motion flexion splinting and hand use is instituted for 12 weeks. Our acute cases obtained as good as, or better range of motion than, conventional management techniques, with early full flexion and maintenance of extension without any recurrences. The most significant difference is morbidity, with ability to preserve hand function during healing and the absence of further therapy after 6 weeks of splinting. Patients with chronic boutonniere deformity presented from 8 weeks to 3 years following injury (averaging 31 weeks) and were 15 to 99 years of age (averaging 42 years). All were serially casted to less than -20° (averaging -4°) and maintained that level of extension after 3 months of relative motion flexion splinting. All achieved flexion to their palm, and all met the Steichen-Strickland chronic boutonniere classification of "excellent." There were no recurrent progressive boutonniere deformities in either acute or chronic cases and no instances of reflex sympathetic dystrophy/chronic regional pain syndrome (RSD/CRPS). Relative motion flexion splinting affords early active motion and hand use with excellent range of motion achieved following acute open boutonniere repair or closed boutonniere rupture with less morbidity than conventional management. Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension, and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion. No further therapy was needed in our cases. We believe this management technique should be attempted for chronic boutonniere deformity as a preferable alternative to surgery, which remains an option if needed.

Infrared thermographic evaluation using an air convection cooling device to study regional complex pain syndrome

To review the importance of physical examination in the diagnostic process of musculoskeletal conditions vis-a-vis the development of sensitive and powerful technologies such as MRI and high-resolution ultrasound. Because the physical examination of the musculoskeletal system is an exercise of applied clinical anatomy, the authors tested, in one-to-one practical examinations, the basal knowledge of musculoskeletal anatomy of rheumatology trainees, rheumatologists, and other professionals of musculoskeletal medicine. The results of the authors' surveys were disappointing, with a correct response rate of 50 to 60% depending on the locales. To correct this deficit, the authors gave many active-learning, case-centered seminars throughout the Americas and some overseas that may have fostered an interest in the study of clinical anatomy. There was an increased interaction between anatomy departments and clinicians, and that daily use of clinical anatomy would make anatomy relevant, improve clinical skills, and probably reduce the overall costs of the health care system.Key Points• Knowledge of musculoskeletal anatomy is the basic diagnostic tool in the regional pain syndromes• Knowledge of musculoskeletal anatomy helps understand the musculoskeletal involvement in the regional and systemic rheumatic disorders• An active-learning methodology was used since 2006 to review the anatomy that is relevant for rheumatology trainees and practitioners of musculoskeletal medicine• A skilled, anatomy-based physical examination and a well-thought diagnostic hypothesis could reduce the use of expensive technologies that, being too sensitive, may lead the unaware clinician astray.

Background: Myofascial pain syndrome is a common pain condition characterized by a key symptoms and signs, determined by multiple etiologies, comorbid with a variety of systemic diseases and regional pain syndromes and managed by diverse therapies with variable outcomes.
 Objective: This study aimed to concisely report 11 cases of myofascial pain syndrome managed by myofascial trigger point therapy.
 Methods: The relevant information about 11 cases was collected prospectively using a semistructured proforma. All patients were diagnosed mainly by detailed history and gold standard palpation method that helps identify taut muscles, tender myofascial trigger points, local twitch response and autonomic manifestations.
 Results: Most of the patients with variable age and profession presented in emergency room with acute pain, limited motion, weakness, referred pain of specific pattern and associated autonomic signs and symptoms. Myofascial trigger point therapy alone with a timeline of about 30-60 minutes of 1-3sessions brought about good results in all 11 patients (100%) who remained stable at two to three months followup.
 Conclusion: Myofascial pain syndrome linked with latent or active myofascial trigger points developed due to repeated strains and injuries needs to be diagnosed by history and palpation method, systemic evaluation and laboratory investigations. Though several interventions are used in myofascial pain syndrome, myofascial trigger point massage therapy alone is found to be reasonably effective with excellent results. This clinical case series is calling for double-blind randomized controlled trials among patients with myofascial pain syndrome not only in Saudi Arabia but also in other Middle East countries in future.

Cross-cultural adaptation of the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) in a Colombian population

BackgroundWe aimed to explore the American College of Rheumatology (ACR) 1990 and 2011 fibromyalgia (FM) classification criteria’s items and the components of Fibromyalgia Impact Questionnaire (FIQ) to identify features best discriminating FM features. Finally, we developed a combined FM diagnostic (C-FM) model using the FM’s key features.MethodsThe means and frequency on tender points (TPs), ACR 2011 components and FIQ items were calculated in the FM and non-FM (osteoarthritis [OA] and non-OA) patients. Then, two-step multiple logistic regression analysis was performed to order these variables according to their maximal statistical contribution in predicting group membership. Partial correlations assessed their unique contribution, and two-group discriminant analysis provided a classification table. Using receiver operator characteristic analyses, we determined the sensitivity and specificity of the final model.ResultsA total of 172 patients with FM, 75 with OA and 21 with periarthritis or regional pain syndromes were enrolled. Two steps multiple logistic regression analysis identified 8 key features of FM which accounted for 64.8% of variance associated with FM group membership: lateral epicondyle TP with variance percentages (36.9%), neck pain (14.5%), fatigue (4.7%), insomnia (3%), upper back pain (2.2%), shoulder pain (1.5%), gluteal TP (1.2%), and FIQ fatigue (0.9%). The C-FM model demonstrated a 91.4% correct classification rate, 91.9% for sensitivity and 91.7% for specificity.ConclusionsThe C-FM model can accurately detect FM patients among other pain disorders. Re-inclusion of TPs along with saving of FM main symptoms in the C-FM model is a unique feature of this model.

Adecuación y validación transcultural del cuestionario COPCORD: Programa Orientado a la Comunidad para el Control de las Enfermedades Reumáticas en Colombia

Background: Myofascial pain syndrome is a common multifactorial condition that presents with key manifestations and comorbid with many systemic diseases and regional pain syndromes. Objective: This study aims to concisely review clinical, diagnostic and integrative therapeutic aspects of myofascial pain syndrome.
 Methods: E-searches (2000-2019) using keywords and Boolean operators were made and using exclusion and inclusion criteria, 50 full articles that focused on myofascial pain syndrome were retained for this review.
 Results: Myofascial pain syndrome is a multidimensional musculoskeletal disorder with ill-understood etiopathogenesis and pathophysiology and characterized by tender taut muscle with myofascial trigger points, muscle twitch response, specific pattern of referred pain and autonomic symptoms. A variety of pharmacological and nonpharmacological therapies with variable efficacy are used in myofascial pain syndrome, the latter modalities such as education, stretching and exercises, moist hot and cold packs, dry needling and myofascial massage or myofascial trigger point massage are used as first line options.
 Conclusion: Myofascial pain syndrome and trigger points initiated by repeated strains and injuries co-occur with diverse physical diseases and regional pain syndromes, which need comprehensive diagnostic evaluation using multiple methods. Several interventions are used in patients with myofascial pain syndrome who effectively respond to myofascial massage. This study calls for exploring etiopathogenesis and basic pathophysiological mechanisms underlying myofascial pain syndrome in future.