Acupuncture in the Multimodal Biopsychosocial Pain Management. <br>Towards a New Model in Clinical Practice

The last decennia the multidimensional nature of pain has been recognized and a multimodal bio-psychosocial management has been proposed. Acupuncture has progressively gained a place in this multimodal approach. The principles of traditional Chinese medicine link three major themes, nutrition and microbiome, neuroplasticity, homeostasis and the side effects of medication. For patients with chronic pain and/or chronic pain refractory to conservative medicine it is important to assess all factors involved with the chronicity. The improved biological, genetic and epigenetic knowledge has contributed to a better understanding of the mechanism of action of acupuncture and integrative medicine. Moreover neuroimaging has been able to demonstrate the brain regions activated by acupuncture and also illustrates the differences with sham or placebo. Opponents often claim an absence or weakness of evidence. These claims are based on the observations that the initial reports are predominantly case reports and studies with a poor design quality. In the last decennia well-designed randomized trials have been published, thus improving the quality of the evidence. The most important findings are summarized in this article. As with all controlled trials the inclusion and exclusion criteria as well as the standardization of the treatment do not always reflect daily practice. Therefore we report patient cases as illustration of the integrative approach.

H-MR Spectroscopy of the Anterior Cingulated Cortex: Usefulness in the Prediction of Patients That Will Benefit from a Cognitive Behavioural Therapy in the Treatment of Chronic Pain

Anterior cingulated cortex (ACC) is involved in “the state in which patients do not care much about pain despite its presence” which is a goal of psychosomatic treatment. To investigate the absolute concentration of N-acetylaspartate (NAA) in the anterior cingulated cortex (ACC) as predictors of patients that may benefit from cognitive behavioural therapy in the treatment of chronic pain. Proton magnetic resonance spectroscopy (1H-MRS) was performed with a 1.5 T MR system on a voxel in the bilateral ACC in 85 chronic pain patients and 20 age-matched normal control subjects. Eighteen out of 24 (75.0%) patients whose NAA concentration decreased significantly in the ACC, respectively, compared to the mean NAA concentration of the normal control subjects, needed cognitive behavioural therapy. Our results suggest that decreased NAA concentration in the ACC is associated with the necessity of cognitive behavioural therapy. 1H-MRS may serve as a useful non-invasive tool for evaluating chronic pain patients.

Simultaneous Occurrence of Myofascial Pain Referred to Tooth and Endodontic Lesions in Patient with Toothache: A Case Report

Toothache is almost always caused by odontogenic toothache, but diagnosis is more difficult in the case of nonodontogenic toothache. We report a case of simultaneous occurrence of odontogenic and nonodontogenic toothache. This manuscript presents a case report for a 35-year-old woman who visited our Orofacial and Head Pain Clinic with the chief complaint of continuous dull pain in left maxillary molar teeth region. It was concluded to be a case of simultaneous odontogenic toothache and nonodontogenic toothache. It was successfully treated by an endodontist and an orofacial pain specialist. The endodontist performed root canal treatment against odontogenic toothache caused by apical periodontitis using a dental operating microscope. The presence of a trigger point (TP) resulting in tooth pain was inferred. A trigger point injection (TPI) was administered by orofacial pain specialist, and toothache relief was confirmed. Myofascial pain was diagnosed definitively. After confirming that the toothache had resolved at multiple TPIs, a crown prosthesis was placed. Following the application of crown prosthesis, we were concerned but did not find recurrence of toothache from myofascial pain due to increased occlusal force. This case suggests that there is no single cause of chronic pain and that multiple causes must be considered for diagnosis, suggesting the need for treatment by multiple specialists.

Screening Survey of Pain Intensity in Patients with Temporomandibular Disorders

Objective: Pain tends to be the chief complaint in patients suffering temporomandibular disorders (TMD). Previous studies on pain and psychosocial factors have reported on the relationship between presence of pain and mental disorders. To date, however, few studies have addressed the relationship between intensity of pain and psychosocial factors. In this study, we investigated the relationship between intensity of pain and age, gender, palpation scores (PPS), tendencies toward depression, anxiety, and somatization, and oral parafunctional habits. Methods: This screening survey encompassed 104 patients (70 women and 34 men;mean age of 46.1 ± 19.3) who visited our clinic. We gathered the following data: age;gender;PPS included in Axis I diagnosis;and characteristic pain intensity (CPI), depression, anxiety, somatization, and oral parafunctional habits (assessed by the Oral Behavior Checklist) included in Axis II diagnosis. Based on the results of CPI, we divided patients into two groups: those experiencing low pain intensity (LP group) and those experiencing high pain intensity (HP group). The statistically significant level was set to below 5%. IBM SPSS Statistics V25 was used to perform all statistical analyses. Results: We observed no gender differences between LP and HP groups. The HP group included significantly more patients with higher scores for depression, anxiety, somatization, and oral parafunctional habits than the LP group. While no gender differences were observed in CPI, depression, anxiety, somatization, and oral parafunctional habits were significantly more common in women than in men. We observed no differences in age or PPS between the LP and HP groups. However, scores for depression, anxiety, somatization, and oral parafunctional habits were significantly higher in the HP group than in the LP group. We performed multiple regression analysis using the CPI score as the dependent variable and scores for depression, anxiety, somatization, and oral parafunctional habits as independent variables in both the LP and the HP groups. We identified no significant predictors for the LP group, but extracted depression as a significant predictor in the HP group. On evaluating the correlation of PPS with depression, anxiety, somatization, and oral parafunctional habits in both the LP and the HP groups, we found no correlation between the PPS and the seven-item generalized anxiety disorder (GAD-7) scale in the LP group but identified a significant correlation between the PPS and GAD-7 scores in the HP group. Moreover, the correlation coefficient between the patient health questionnaire (PHQ)-9 and GAD-7 scores was higher in the HP group than in the LP group. Conclusion: In those reporting more intense pain, we found a stronger correlation among psychological factors in patients diagnosed with TMD. Greater tendency toward depression was directly associated with pain intensity. The results point to the need to consider differences in psychosocial factors associated with pain intensity when treating TMD.

MicroRNA regulatory pattern in spinal cord ischemia-reperfusion injury

After spinal cord injury, dysregulated miRNAs appear and can participate in inflammatory responses, as well as the inhibition of apoptosis and axon regeneration through multiple pathways. However, the functions of miRNAs in spinal cord ischemia-reperfusion injury progression remain unclear. miRCURY LNATM Arrays were used to analyze miRNA expression profiles of rats after 90 minutes of ischemia followed by reperfusion for 24 and 48 hours. Furthermore, subsequent construction of aberrantly expressed miRNA regulatory patterns involved cell survival, proliferation, and apoptosis. Remarkably, the mitogen-activated protein kinase(MAPK) signaling pathway was the most significantly enriched pathway among 24-and 48-hour groups. Bioinformatics analysis and quantitative reverse transcription polymerase chain reaction confirmed the persistent overexpression of miR-22-3 p in both groups. These results suggest that the aberrant miRNA regulatory network is possibly regulated MAPK signaling and continuously affects the physiological and biochemical status of cells, thus participating in the regulation of spinal cord ischemia-reperfusion injury. As such, miR-22-3 p may play sustained regulatory roles in spinal cord ischemia-reperfusion injury. All experimental procedures were approved by the Animal Ethics Committee of Jilin University, China [approval No. 2020(Research) 01].

Effect of captopril on serum TNF-α level in acute lung injury rats induced by HCL

Objective:To observe the effect of captopril on the tumor necrosis factor-α(TNF- α) level and arterial blood gases in acute lung injury(All) induced by HCL in rats,and to analyze its protective mechanism.Methods:Fifty Wistar rats were selected and randomly divided into three groups,with 20 rats in Group Ⅰ and Ⅱ,respectively and 10 animals in Group Ⅲ.ALI model was constructed by intratracheal injection of diluted hydrochloric acid(pH=1.25.1.2 mL/kg).Group Ⅰrats received not any treatment after construction of AM model.Group Ⅱ rats were treated with captopril(5 mg/kg,i.p.) 5 min after induction of ALI.Group Ⅲ served as normal control without any treatment.Ninety minutes after construction of ALI model,all the rats were sacrificed.Blood was withdrawn for detection of TNF- α level and arterial blood gases index.And lung tissue slices of the three groups were prepared for observation of pathologic histology changes.Results:TNF- α level in serum of Group Ⅰ and Ⅱ rats was significantly higher than that in Group Ⅲ(P<0.05),while TNF- α level in serum of Group Ⅱ was significantly lower in Group Ⅰ(P<0.05).PaCO_2 level was significantly higher(P<0.05),while PaO_2 was significantly lower(P<0.05) in Group Ⅰ and Ⅱ rats than those in Group Ⅲ.PaCO_2 was significantly lower(P<0.05) and PaO_2 was significantly higher(P<0.05) in Group Ⅱ than those in Group Ⅰ.Histological observation showed diffuse congestion and severe edema of luug tissue,obvious thickening and structure damage of alveolar walls and a large amount of neutrophil infiltration in Group Ⅰ rats.Group Ⅱ rats showed mild edema of lung tissue;only a small portion of alveolar walls showed thickening and only a few of neutrophil infiltration could be observed.The degree of injury was remarkably slighter than that of Group Ⅰ rats.Group Ⅲ rats showed clear lung tissue structure and normal morphology:alveolar walls were uniform and the margin was smooth and few neutrophil could be observed.Conclusions:Captopril can significantly reduce serum TNF- α level,elevate PaO_2 and reduce PaCO_2 in rats with ALI.It has a protective effect on ALI rats.

Effects of Intrathecally Administerd NaV1.8 Antisense Oligonucleotide on the Expression of Sodium Channel mRNA in Dorsal Root Ganglion

Neuropathic pain has been hypothesized to be the result of aberrant expression and function of sodium channels at the site of injury. To investigate the effects of NaV1.8 antisense oligonucleotide on the expression of sodium channel mRNA in dorsal root ganglion （DRG） neurons in chronic neuropathic pain. 24 Sprague-Dawley rats weighing 200--260 g were anesthetized with the intraperitoneal injection of 300 mg· kg^-1 choral hydrate. The CCI model was made by loose ligation of sciatic nerve trunk by 4--0 chromic gut. The mechanical and thermal pain threshold were measured before operation and 1, 3, 5, 7, 9, 11, 13 days after operation. A PE-10 catheter was implanted in subarachnoid space at lumbar region. On the 7th postoperative day the animals were randomly divided into 4 groups. The drugs were injected intrathecally twice a day for 5 consecutive days in group 2--4. The animals were decapitated 14 days after the surgery. The L4--L6 DRG of the operated side was removed and crushed, and total RNA was extracted with Trizol reagent. The contralateral side was used as control. The change of NaV1.8 sodium channel transcripts was determined by RT-PCR. Pain threshold was significantly lowered after CCI as compared with that in control group and was elevated 3 days after antisense oligonucleotide injection. Sensory neuron specific TTX-R sodium channel NaV1.8 transcript was down-regulated after antisense oligonucleotide injection at the dosage of 45 μg as compared with that in CCI group （P〈0.01）, and it was even greater at the dosage of 90 μg. The intrathecally injected NaV1.8 antisense oligonucleotide can reduce the mechanical allodynia and thermal hyperalgesia partially by downregulating the SNS transcript expression.

Ultrasound-guided rectus sheath block for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery:A case report

BACKGROUND Anterior cutaneous nerve entrapment syndrome is defined as abdominal pain due to entrapped intercostal nerves.This is the first report of a patient successfully treated for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery with an ultrasound-guided rectus sheath block.The rectus sheath block physically lysed adhesions and relieved pain from anterior cutaneous nerve entrapment syndrome.CASE SUMMARY The patient is a 44-year-old man who presented with severe left upper abdominal pain at an operative scar one month after laparoscopic ulcer repair.Diagnosis and treatment were performed using an ultrasound-guided rectus sheath block with 0.1%lidocaine 20 mL.The pain was relieved after the block.The diagnosis was anterior cutaneous nerve entrapment syndrome.Rectus sheath block may be effective for patients with anterior cutaneous nerve entrapment syndrome.CONCLUSION Ultrasound-guided rectus sheath block is a promising treatment modality for patients with postoperative anterior cutaneous nerve entrapment syndrome due to adhesions.

Successful Treatment of a Case of First Bite Syndrome without Any Cause

Background: For the first bite syndrome (FBS), various causes were suggested such as parapharyngeal space surgery, resection of styloid process, carotid endarterectomy, parotid gland tumor, submandibular gland tumor, and upper cervical surgery. Actually, the real cause of FBS is still not clear. Also, suggested methods of treatment for the FBS are botulinum toxin injection, laser tympanic plexus ablation, pharmacologic approach, and no treatment. The results of those treatments were not satisfactory. Aim: The authors tried to find out the adequate method of treatment for the FBS and also tried to figure out pathologic cause of the FBS through observation of the patient response to the treatment. Case Presentation: A 38-year-old male was presented at head and neck surgery clinic with a sharp pain on the left parotid area especially at the first bite of eating food for two days. There was no cause. The patient was given trigger point injections on his left sternocleidomastoid, masseter, and temporal muscles with left mandibular nerve block five times 3 - 4 days apart. Also small amount of oral anticonvulsants were added for four weeks. Before finishing taking oral medication, the pain was gone completely. Conclusion: The authors experienced a case of FBS with no detectable cause, and treated successfully with the methods of trigger point injection, mandibular nerve block, and oral antiepileptic medication.

硬膜外激素和局部麻醉以预防疱疹后神经痛的PINE研究:一项随机对照试验

Background: Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. We assessed the effectiveness of a single epidural injection of steroids and local anaesthetics for prevention of postherpetic neuralgia in older patients with herpes zoster. Methods: We randomly assigned 598 patients older than 50 years, with acute herpes zoster (rash < 7 days) below dermatome C6, to receive either standard therapy (oral antivirals and analgesics) or standard therapy with one additional epidural injection of 80 mg methylprednisolone acetate and 10 mg bupivacaine. The primary endpoint was the proportion of patients with zoster-associated pain 1 month after inclusion. Analyses were by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN32866390. Findings: At 1 month, 137 (48% ) patients in the epidural group reported pain compared with 164 (58% ) in the control group (relative risk [RR] 0.83, 95% CI 0.71- 0.97, p=0.02). After 3 months these values were 58 (21% ) and 63 (24% ) respectively (0.89, 0.65- 1.21, p=0.47) and, at 6 months, 39 (15% ) and 44 (17% ; 0.85, 0.57- 1.13, p=0.43). We detected no subgroups in which the relative risk for pain 1 month after inclusion substantially differed from the overall estimate. No patient had major adverse events related to epidural injection. Interpretation: A single epidural injection of steroids and local anaesthetics in the acute phase of herpes zoster has a modest effect in reducing zoster-associated pain for 1 month. This treatment is not effective for prevention of long-term postherpetic neuralgia.

Influence of Organ Pathology on the Electrical Parameters in Organ Projection Areas of the Skin

Pathology of an internal organ causes significant rectification of electrical currents （diode phenomenon） in related skin areas - organ projection areas （OPAs）, once the resistance ‘breakthrough effect＇ has been induced in the skin. Also, the impedance of the diseased organ＇s projection areas is increased. The aim of this double-blind study was to confirm these phenomena statistically using a broad spectrum of measuring parameters. Skin impedance vs. measurement frequency, skin impedance vs. applied voltage, and skin resistance vs. voltage were evaluated at 335 auricular OPAs related to the healthy internal organs and 203 auricular OPAs related to the diseased organs. These measurements confirmed that the skin electrical characteristics of specific locations are dependent on the health state of the corresponding internal organs. It was found that the impedance of OPAs corresponding to the healthy internal organs equals 185 ＋ 291 k,Q at 10Hz and decreases to 64 ± 49 kΩ at 10kHz; and that the impedance of OPAs related to the diseased organs equals 7.5 ± 2.2 MΩ at 10Hz and 99 ± 50kΩ at 10kHz. The disparity of the impedances between the healthy and diseased organs related OPAs is greater at higher potentials. The skin resistance, when measured with a negatively polarized point electrode, undergoes a rapid resistance decrease of approximately two orders of magnitude, if the applied current is sufficient. After this reversible ‘breakthrough effect＇ is obtained the skin exhibits rectification. The degree of rectification is low for OPAs related to the healthy organs. For OPAs related to the diseased organs, the resistance measured with a positive polarisation of measuring electrode could be five times greater than the resistance measured at the same voltage with the same but negatively polarised electrode. The disparity between the resistance measured with a negatively and with a positively polarised electrode at OPAs related to the diseased organs was greater at higher measurement voltages. The influence of organ pathology on the electrical parameters of related OPAs does not depend on the kind of internal organ and is not affected by the etiology of pathology. The degree of rectification or difference in impedance is proportional to the extent of the pathological process within the related organ.

Necessity of Magnetic Resonance Imaging (MRI) using an appropriate sequence for diagnosis of trigeminal neuralgia associated with intracranial tumor

Aims: Trigeminal neuralgia is generally caused by neurovascular compression. In rare cases intracranial tumors may also lead to this condition. The present study was conducted to identify clinical symptoms and testing methods that are useful for early detection of trigeminal neuralgia associated with intracranial tumor. Methods: Five patients with trigeminal neuralgia suspected to be due to intracranial tumor, who visited our department for the first time during the period between February 2007 and March 2009, were examined. We analyzed the medical records and MRI findings of these patients. The clinical symptoms of subjects were compared to those presented at the International Classification of Headache Disorders. Results: There were no feature symptoms to trigeminal neuralgia caused by intracranial tumors compared with trigeminal neuralgia in general. None of the patients complained of spontaneous headache and nausea, which are clinical symptoms characteristic of brain tumor. Head MRI at our hospital was the most accurate method to detect intracranial tumors. Finally four of five patients received brain surgery to remove tumors. Conclusion: Small tumors and roots of the trigeminal nerve may not create accurate images by regular head MRI. Therefore, MRI using the imaging sequence which enables accurate visualization of roots of the trigeminal nerve is essential to confirm the presence of tumors in patients with suspected trigeminal neuralgia.

Medial Pterygoid Myositis Complicated by Numbness of the Tongue and Nonodontogenic Toothache: A Case Report

A 34-year-old woman visited our clinic with complaints of trismus, numbness in the left half of the tongue, and pain in tooth 34. At the patient’s initial visit to our clinic, the maximum assisted jaw opening movement was 20 mm, pointing to severe trismus. The patient complained of spontaneous pain in tooth 34 but did not evince percussion pain. Her pain remained unchanged even under local anesthesia. Radiography showed no pathological findings. A tenderness test of masticatory muscles failed to induce pain. The presence of severe trismus argued against temporomandibular disorders, resulting in suspicion of other inflammatory disease. In view of numbness of the tongue, other diseases such as inflammation or neoplastic disease in the head and neck region were considered. The patient was referred to the departments of neurosurgery and otolaryngology for examination. The results of MRI and CT diagnosis led to the identification of acute myositis of the left medial pterygoid muscle requiring the prescription of nonsteroidal anti-inflammatory drugs, and relaxation of mandibular muscles. With time, maximum unassisted jaw opening improved and pain in tooth 34 ceased, but tongue numbness persisted. The condition was attributed to compression of lingual nerve (LN) and mandibular nerve (MN) resulting from medial pterygoid muscle inflammation.

Localization of Auricular Projection Area of the Liver and Its Use in the Monitoring of Viral Hepatitis

Background： Pathology of an internal organ causes significant rectification of electrical currents （diode phenomenon） in related skin areas once the resistance ＇breakthrough effect＇ has been induced in the skin. Objective： Localization of auricular projection area of the liver and evaluation of its usefulness in the monitoring of viral hepatitis. Design, Patients and Setting： Comparative study of the degree of electrical rectification measured at various spots in the auricular concha region, in 19 inpatients with hepatitis B and 15 clinically healthy volunteers, at the Department of Infectious Diseases, Provincial Teaching Hospital, Tychy, Poland. Intervention： Evaluation of electrical rectification at various spots on the auricular concha using a ＂rectification ratio＂ that quantifies the degree of rectification （normal range： 0-60%）. Main outcome measure： The location of the skin area where a statistically significant difference existed between the rectification ratios was observed in patients （82±12% at the time of the ＇peak period＇） versus controls （42±8%）. Results： A location was identified on the ear auricle where the electrical rectification phenomenon demonstrated a dependence on the presence of hepatitis. Conclusions： Liver projection area exists on the ear auricle which is located within the region of cymba conchae, next to anthelix and the cavity of concha. The existence of viral hepatitis causes this skin area to show a higher degree of electrical rectification once the skin resistance ＇breakthrough effect＇ has been induced. Evaluation of the rectification phenomenon of the liver proiection area provides a method of non-invasive monitoring of viral hepatitis.

The Effects of Anma (Traditional Japanese Massage)—Randomised Trial

Background and Objective: Anma is a traditional Japanese bodywork therapy that has not been widely known and used in the West. There have been only a few Anma studies published in English journals. To study the effect of Anma (traditional Japanese massage) among participants who have neck and shoulder stiffness symptoms (so-called Katakori, in Japanese). Methods: The study participants consisted of seventy-seven (Study 1), thirteen (Study 2), and twenty (Study 3) adults with “Katakori” symptoms. The research design is as follows: (Study1) Randomized, Parallel-Group, Controlled Trial. (Study 2) Crossover Clinical Trial. (Study 3) Randomized, Parallel-Group, Controlled Trial. And we conducted Anma treatment for 45 minutes (Treatment) or rest in lying position for 45 minutes (Control). Results: In study 1, the symptom of “Katakori” was relieved after Anma treatment in Anma group (p d: 2.2). There was a significant interaction between the Anma group and the control group (p < 0.001). In study 2, MBV significantly increased following Anma treatment. There was a significant interaction between the Anma group and the control group (p = 0.022). In study 3, the symptom of “Katakori” was relieved after Anma treatment in the treatment group. There were no significant interactions between the groups in VAS and MBV values. Discussion and Conclusions: The study demonstrated that Anma therapy decreases “Katakori” symptoms while increasing MBV in the shoulder region.

Evaluating Training Programs for Electroacupuncture Techniques with Skin Temperature as a New Index

Training in acupuncture techniques has a long history of thousands of years. It has been individually handed down from person (teacher) to person (student). However, techniques and training have not been scientifically evaluated because individual differences may exist among evaluators. In animal studies, some researchers have reported that acupuncture stimulation dilates blood vessels of the skin and skeletal muscles. These studies also reveal an association between skin temperature (ST) and blood circulation volume on the skin. Our previous studies have reported that acupuncture stimulation, especially that of electroacupuncture (EA), can elevate ST. Therefore, we monitored the instructive effects and level of EA techniques with ST and propose that we can bring monitoring ST into training/education of EA as a new index of technical assessment. Moreover, ratio of changes might be used as new criteria for retraining. Healthy students (n = 14) were given with 10 minutes of EA stimulation on the tibialis anterior: Zusanli (ST36) and Tiaokou (ST38). Their ST was monitored before and during stimulation as well as for 30 minutes after stimulation. All subjects showed a nominal increase in ST. At the time, ratios of changes were also calculated. Two subjects did not reach the average of 1.3%. This suggests that the technical level of the therapist was inadequate. Thus, observation of ST elevation and calculation of the average ratio of ST change (elevation) could be applied to a new scientific index of technical assessment in acupuncture treatment training. However, further research (e.g., larger-scale studies, adjustment for gender differences, or other age subjects) is required to support these findings.

Effect of Disc Position for Acute Closed Lock of the Temporomandibular Joint

In this manuscript, the authors have studied the Disc Displacement (DD) status of patients with acute Closed Lock (CL) to determine differences between DD with Reduction (DDwR) and DD without Reduction (DDwoR). Among the acute CL patients who visited our hospital within 2 weeks of the onset of CL, we studied 10 patients whose CL was released (DDwR) and 13 patients whose CL was not released (DDwoR). The DDwoR group was significantly older than the DDwR group. Although the mouth opening distance was significantly greater in the DDwoR group than in the DDwR group, the two groups were identical in the duration of CL. Sagittal MRI images showed no significant differences between the two groups in disc length and disc thickness (anterior band, intermediate zone, and posterior band). Multisection sagittal and coronal images identified lateral DD in 7 of the 10 patients in the DDwR group, although no specific direction of the DD was observed in the DDwoR group. Furthermore, deformation of the medial disc was common in the DDwoR group but uncommon in the DDwR group.

How Can We Give Hope for Cancer Patients to Cure This Disease?

When writing this article,the author feels certain that what she is going to say will give hope to those who are experiencing cancer problems and are not seeing improvement with their current treatment protocols[1].With the implementation of the Flexner report in 1913,modern medicine was born with the implementation of increasingly specialized processes for the diagnosis and treatment of various pathologies,especially cancer[2,3].The super specialization of medicine in modern medical practice has resulted in medical doctors that only look at the patients’symptoms and the resulting treatment is usually focused in a localized way.This model of reasoning was made by Galen(129 C.E.-216 C.E.)that was a Greek medical doctor who wrote many books regarding the anatomy of the human body.Galen divided the human into systems and one organ works separately from each other,independently[4].

Understanding of myofascial trigger points

Objective To investigate the current practice of myofascial pain syndrome （MPS） including current epidemiology, pathology, diagnosis and treatment. Data sources The data analyzed in this review were mainly from relevant articles without restriction on the publication date reported in PubMed, MedSci, Google scholar. The terms ＂myofasial trigger points＂ and ＂myofacial pain syndrome＂ were used for the literature search. Study selection Original articles with no limitation of research design and critical reviews containing data relevant to myofascial trigger points （MTrPs） and MPS were retrieved, reviewed, analyzed and summarized. Results Myofascial pain syndrome （MPS） is characterized by painful taut band, referred pain, and local response twitch with a prevalence of 85% to 95% of incidence. Several factors link to the etiology of MTrPs, such as the chronic injury and overload of muscles. Other factors, such as certain nutrient and hormone insufficiency, comorbidities, and muscle imbalance may also maintain the MTrP in an active status and induce recurrent pain. The current pathology is that an extra leakage acetylcholine at the neuromuscular junction induces persistent contracture knots, relative to some hypotheses of integration, muscle spindle discharges, spinal segment sensitization, ect. MTrPs can be diagnosed and localized based on a few subjective criteria. Several approaches, including both direct and supplementary treatments, can inactivate MTrPs. Direct treatments are categorized into invasive and conservative. Conclusion This review provides a clear understanding of MTrP pain and introduces the most useful treatment approaches in China.