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Objective The nociceptive pain processing of soft-tissue overuse conditions is under debate because no consensus currently exists. The purpose of this meta-analysis was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas in 2 groups: participants with symptomatic lower extremity overuse soft-tissue conditions and controls who were pain free. Methods Five databases were searched from inception to December 1, 2021, for case–control studies comparing PPTs between individuals presenting with symptomatic lower extremity tendinopathy/overuse injury and controls who were pain free. Data extraction included population, diagnosis, sample size, outcome, type of algometer, and results. The methodological quality (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development, and Evaluation) were assessed. Meta-analyses of symptomatic, segmental related, and distant pain-free areas were compared. Results After screening 730 titles and abstracts, a total of 19 studies evaluating lower extremity overuse conditions (Achilles or patellar tendinopathy, greater trochanteric pain syndrome, plantar fasciitis, and iliotibial band syndrome) were included. The methodological quality ranged from fair (32%) to good (68%). Participants with lower extremity overuse injury had lower PPTs in both the painful and nonpainful areas, mirrored test-site, compared with controls (affected side: mean difference [MD] = −262.92 kPa, 95% CI = 323.78 to −202.05 kPa; nonaffected side: MD = −216.47 kPa, 95% CI = −304.99 to −127.95 kPa). Furthermore, people with plantar fasciitis showed reduced PPTs in the affected and nonaffected sides at segmental-related (MD = −176.39 kPa, 95% CI = −306.11 to −46.68 kPa) and distant pain-free (MD = −97.27 kPa, 95% CI = 133.21 to −61.33 kPa) areas compared with controls. Conclusion Low- to moderate-quality evidence suggests a reduction of PPTs at the symptomatic area and a contralateral/mirror side in lower extremity tendinopathies and overuse conditions compared with pain-free controls, particularly in plantar fasciitis and greater trochanteric pain syndrome. Participants with plantar fasciitis showed a reduction of PPTs on the affected and non-affected sides at a segmental-related area (very low-quality evidence) and at a remote asymptomatic area (moderate-quality evidence). Impact Some overuse peripheral pain conditions may be more associated with pressure pain sensitivity than others. Accordingly, examination and identification of conditions more peripherally, centrally, or mixed mediated could potentially lead to more specific and different treatment strategies. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to develop a data-driven Bayesian network approach to understand the potential multivariate pathways of the effect of manual physical therapy in women with carpal tunnel syndrome (CTS). Methods. Data from a randomized clinical trial (n=104) were analyzed comparing manual therapy including desensitization maneuvers of the central nervous system versus surgery in women with CTS. All variables included in the original trial were included in a Bayesian network to explore its multivariate relationship. The model was used to quantify the direct and indirect pathways of the effect of physical therapy and surgery on short-term,mid-term, and long-term changes in the clinical variables of pain, related function, and symptom severity. Results. Manual physical therapy improved function in women with CTS (between-groups difference: 0.09; 95% CI=0.07 to 0.11). The Bayesian network showed that early improvements (at 1 month) in function and symptom severity led to longterm (at 12 months) changes in related disability both directly and via complex pathways involving baseline pain intensity and depression levels. Additionally, women with moderate CTS had 0.14-point (95% CI=0.11 to 0.17 point) poorer function at 12 months than those with mild CTS and 0.12-point (95% CI=0.09 to 0.15 point) poorer function at 12 months than those with severe CTS. Conclusion. Current findings suggest that short-term benefits in function and symptom severity observed after manual therapy/surgery were associated with long-term improvements in function, but mechanisms driving these effects interact with depression levels and severity as assessed using electromyography. Nevertheless, it should be noted that betweengroup differences depending on severity determined using electromyography were small, and the clinical relevance is elusive. Further data-driven analyses involving a broad range of biopsychosocial variables are recommended to fully understand the pathways underpinning CTS treatment effects. Impact. Short-term effects of physical manual therapy seem to be clinically relevant for obtaining long-term effects in women with CTS. [ABSTRACT FROM AUTHOR]

Objective Current evidence suggests that carpal tunnel syndrome (CTS) involves widespread pressure pain sensitivity as a manifestion of central sensitization. This study aimed to quantify mechanisms driving widespread pressure pain hyperalgesia in CTS by using network analysis. Design Cross-sectional. Setting Urban hospital. Subjects Women with CTS (n=120) who participated in a previous randomized clinical trial. Methods Pain intensity, related function, symptom severity, depressive levels, and pressure pain threshold (PPTs) over the median, radial, and ulnar nerves, as well as the cervical spine, the carpal tunnel, and the tibialis anterior, were collected. Network analysis was used to quantify the adjusted correlations between the modeled variables and to determine the centrality indices of each variable (i.e. the degree of connection with other symptoms in the network). Results The estimated network showed several local associations between clinical variables and the psychophysical outcomes separately. The edges with the strongest weights were those between the PPT over the median nerve and the PPT over the radial nerve (P =0.34), between function and depressive levels (P =0.30), and between the PPT over the carpal tunnel and the PPT over the tibialis anterior (P =0.29). The most central variables were PPT over the tibialis anterior (the highest Strength centrality) and PPT over the carpal tunnel (the highest Closeness and Betweenness centrality). Conclusions This is the first study to apply network analysis to understand the multivariate mechanisms of individuals with CTS. Our findings support a model in which clinical symptoms, depression, and widespread pressure pain sensitivity are connected, albeit within separate clusters. The clinical implications of the present findings, such as the development of treatments targeting these mechanisms, are also discussed. [ABSTRACT FROM AUTHOR]

Objective The presence of altered nociceptive pain processing in patients with upper extremity tendinopathy/overuse injury is conflicting. Our aim was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas between patients with upper extremity tendinopathy/overuse injury and controls. Methods Five databases were searched from inception to October 15, 2020. The authors selected case-control studies comparing PPTs between individuals with upper extremity tendinopathy/overuse injury and pain-free controls. Data were extracted for population, diagnosis, sample size, outcome, and type of algometer. Results were extracted by 3 reviewers. The methodological quality/risk of bias (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development and Evaluation approach) were assessed. Meta-analyses of symptomatic, segment-related, and distant pain-free areas were compared. Results The search identified 807 publications with 19 studies (6 shoulder, 13 elbow) eligible for inclusion. The methodological quality ranged from fair (48%) to good (37%). Patients exhibited lower bilateral PPTs than controls at the symptomatic area (affected side: MD = −175.89 kPa [95% CI = −220.30 to −131.48 kPa]; nonaffected side: MD = −104.50 kPa [95% CI = −142.72 to −66.28 kPa]) and the segment-related area (affected side: MD = −150.63 kPa [95% CI = −212.05 to −89.21 kPa]; nonaffected side: MD = −170.34 kPa [95% CI = − 248.43 to −92.25]) than controls. No significant differences in PPTs over distant pain-free areas were observed. Conclusion Low to moderate quality evidence suggests bilateral hypersensitivity to pressure pain at the symptomatic and contralateral/mirror areas in patients with upper extremity tendinopathies/overuse injury. Moderate quality of evidence supports bilateral pressure pain sensitivity in the segment-related area (neck) in lateral epicondylalgia, but not in subacromial impingement syndrome. No evidence of widespread pressure pain hyperalgesia was reported. Impact Early identification of people with altered pain modulation could guide clinicians in treatment strategies. This review shows that there is a complex interplay between peripheral and central pain mechanisms in upper extremity tendinopathies/overuse injuries and that there likely are different subgroups of patients with upper extremity conditions. [ABSTRACT FROM AUTHOR]

Background Tendon dry needling is a potential treatment for tendinopathies. Several hypotheses have been proposed to explain its underlying mechanisms. No studies (to the best of our knowledge) have investigated changes in gene expression. Objective To investigate histological and gene expression changes after the application of dry needling to the healthy Achilles tendons of rats. Methods Six Sprague-Dawley male rats were randomly divided into two groups: no intervention or dry needling. Dry needling consisted of three sessions (once per week) to the Achilles tendon. Molecular expression of several genes involved in tendon repair and remodeling (e.g. Cox2 , Mmp2 , Mmp9 , Col1a1 , Col3a1 , Vefg , and Scx) was assessed 7 days after the last needling session (day 28) or 28 days after for the no-intervention group. Histological tissue changes were determined with hematoxylin-eosin analyses. Results The hematoxylin-eosin–stained images revealed no substantial differences in collagen structure or the presence of inflammatory cells between the dry needling and no-intervention groups. A significant increase in the molecular expression of Cox2 , Mmp2 , Col3a1 , and Scx genes was observed in Achilles tendons treated with dry needling when compared with the no-intervention group. Conclusion This animal pilot study found that the application of dry needling to the healthy Achilles tendons of rats is able to increase the expression of genes associated with collagen regeneration and tissue remodeling of the extracellular matrix with no further histological damage to the tendon. [ABSTRACT FROM AUTHOR]

Objective No study to our knowledge has investigated the effects longer than 1 year of manual therapy in carpal tunnel syndrome (CTS). The purpose of this study was to investigate the effects of manual therapy versus surgery at 4-year follow-up and to compare the post-study surgery rate in CTS. Methods This randomized controlled trial was conducted in a tertiary public hospital and included 120 women with CTS who were randomly allocated to manual therapy or surgery. The participants received 3 sessions of physical therapy, including desensitization maneuvers of the central nervous system or carpal tunnel release combined with a tendon/nerve gliding exercise program at home. Primary outcome was pain intensity (mean and the worst pain). Secondary outcomes included functional status, symptom severity, and self-perceived improvement measured using a global rating of change scale. Outcomes for this analysis were assessed at baseline, 1 year, and 4 years. The rate of surgical intervention received by each group was assessed throughout the study. Results At 4 years, 97 (81%) women completed the study. Between-group changes for all outcomes were not significantly different at 1 year (mean pain: mean difference [MD] = −0.3, 95% CI = −0.9 to 0.3; worst pain: MD = −1.2, 95% CI = −3.6 to 1.2; function: MD = −0.1, 95% CI = −0.4 to 0.2; symptom severity: MD = −0.1, 95% CI = −0.3 to 0.1) and 4 years (mean pain: MD = 0.1, 95% CI = −0.2 to 0.4; worst pain: MD = 0.2, 95% CI = −0.8 to 1.2; function: MD = 0.1, 95% CI = −0.1 to 0.3; symptom severity: MD = 0.2, 95% CI = −0.2 to 0.6). Self-perceived improvement was also similar in both groups. No between-group differences (15% physical therapy vs 13% surgery) in surgery rate were observed during the 4 years. Conclusions In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home. Impact This is the first study to our knowledge to report clinical outcomes and surgical rates during a 4-year follow-up and will inform decisions regarding surgical versus conservative management of CTS. Lay summary Women with CTS may receive similar benefit from a more conservative treatment—manual therapy—as they would from surgery. [ABSTRACT FROM AUTHOR]

Objective To evaluate the cost-effectiveness of the inclusion of trigger point–dry needling (TrP-DN) into an exercise program for the management of subacromial pain syndrome. Methods Fifty patients with unilateral subacromial pain syndrome were randomized with concealed allocation to exercise alone or exercise plus TrP-DN. Both groups were asked to perform an exercise program targeting the rotator cuff musculature twice daily for five weeks. Patients allocated to the exercise plus TrP-DN group also received dry needling during the second and fourth sessions. Societal costs and health-related quality of life (estimated by EuroQol-5D-5L) over a one-year follow-up were used to generate incremental cost per quality-adjusted life-year (QALY) ratios for each intervention. Results Intention-to-treat analysis was possible for 48 (96%) of the participants. Those in the exercise group made more visits to medical doctors and received a greater number of other treatments (P  < 0.001). The major contributor to societal costs (77%) was the absenteeism paid labor in favor of the exercise plus TrP-DN group (P  = 0.03). The combination of exercise plus TrP-DN was less costly (mean difference cost/patient = €517.34, P  = 0.003) than exercise alone. Incremental QALYs showed greater benefit for exercise plus TrP-DN (difference = 2.87, 95% confidence interval = 2.85–2.89). Therefore, the inclusion of TrP-DN into an exercise program was more likely to be cost-effective than an exercise program alone, with 99.5% of the iterations falling in the dominant area. Conclusions The inclusion of TrP-DN into an exercise program was more cost-effective for individuals with subacromial pain syndrome than exercise alone. From a cost-benefit perspective, the inclusion of TrP-DN into multimodal management of patients with subacromial pain syndrome should be considered. [ABSTRACT FROM AUTHOR]