Ultrasound-Guided Musculoskeletal Injections

Musculoskeletal injections serve a variety of diagnostic and therapeutic purposes, with ultrasonography (US) guidance having many advantages: no ionizing radiation, real-time guidance, high spatial resolution, excellent soft tissue contrast, and the ability to identify and avoid critical structures. Sonography can be cost effective and afford flexibility in resource-constrained settings. This article describes US-guided musculoskeletal injections relevant to many radiology practices and provides experience-based suggestions. Structures covered include multiple joints (shoulder, hip), bursae (iliopsoas, subacromial-subdeltoid, greater trochanteric), peripheral nerves (sciatic, radial), and tendon sheaths (posterior tibial, peroneal, flexor hallucis longus, Achilles, long head of the biceps). Trigger point and similar targeted steroid injections, as well as calcific tendinopathy barbotage, are also described.

Effects of dry needling in lower extremity myofascial trigger points: systematic review

Objective: This systematic review was conducted to explore the current evidences on effects of trigger point dry needling as a treatment strategy on pain and range of motion among the subjects with lower extremity myofascial trigger areas. Methods: A systematic review was performed and searched databases including Cochrane Library, PubMed, SPORTDiscus and PEDro. PRISMA guidelines were followed. Inclusion and exclusion of studies were made according to PICOS format. Ten studies were recruited for assessment based on eligibility. Cochrane Risk of Bias tool was used to assess the Randomized and Non-Randomized controlled trials and the methodological assessment was also performed using PEDro 10-point scale. Data synthesis was performed by Vote Counting Method as a descriptive tool. Results: Seven of the total ten studies deemed High score on PEDro and three were scored Fair on the scale. Each of the ten studies documented improvement in the pain over time with the dry needling strategy. None of the studies targeted the other outcomes like anxiety and sleep disturbances related with myofascial trigger points. Conclusion: On basis of the best evidences available dry needling seems to be effective in pain reduction related to lower extremity myofascial trigger points. Evidence also suggests that there is not much positive effect of myofascial trigger point dry needling on depression, anxiety, muscular strength and quality of life. Keywords: Acupuncture therapy, Dry Needling, Lower extremity, Myofascial trigger points Continuous....

Keratins as an Inflammation Trigger Point in Epidermolysis Bullosa Simplex

Epidermolysis bullosa simplex (EBS) is a group of inherited keratinopathies that, in most cases, arise due to mutations in keratins and lead to intraepidermal ruptures. The cellular pathology of most EBS subtypes is associated with the fragility of the intermediate filament network, cytolysis of the basal layer of the epidermis, or attenuation of hemidesmosomal/desmosomal components. Mutations in keratins 5/14 or in other genes that encode associated proteins induce structural disarrangements of different strengths depending on their locations in the genes. Keratin aggregates display impaired dynamics of assembly and diminished solubility and appear to be the trigger for endoplasmic reticulum (ER) stress upon being phosphorylated by MAPKs. Global changes in cellular signaling mainly occur in cases of severe dominant EBS mutations. The spectrum of changes initiated by phosphorylation includes the inhibition of proteasome degradation, TNF-α signaling activation, deregulated proliferation, abnormal cell migration, and impaired adherence of keratinocytes. ER stress also leads to the release of proinflammatory danger-associated molecular pattern (DAMP) molecules, which enhance avalanche-like inflammation. Many instances of positive feedback in the course of cellular stress and the development of sterile inflammation led to systemic chronic inflammation in EBS. This highlights the role of keratin in the maintenance of epidermal and immune homeostasis.

Autophagy in α-Synucleinopathies—An Overstrained System

Alpha-synucleinopathies comprise progressive neurodegenerative diseases, including Parkinson’s disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). They all exhibit the same pathological hallmark, which is the formation of α-synuclein positive deposits in neuronal or glial cells. The aggregation of α-synuclein in the cell body of neurons, giving rise to the so-called Lewy bodies (LBs), is the major characteristic for PD and DLB, whereas the accumulation of α-synuclein in oligodendroglial cells, so-called glial cytoplasmic inclusions (GCIs), is the hallmark for MSA. The mechanisms involved in the intracytoplasmic inclusion formation in neuronal and oligodendroglial cells are not fully understood to date. A possible mechanism could be an impaired autophagic machinery that cannot cope with the high intracellular amount of α-synuclein. In fact, different studies showed that reduced autophagy is involved in α-synuclein aggregation. Furthermore, altered levels of different autophagy markers were reported in PD, DLB, and MSA brains. To date, the trigger point in disease initiation is not entirely clear; that is, whether autophagy dysfunction alone suffices to increase α-synuclein or whether α-synuclein is the pathogenic driver. In the current review, we discuss the involvement of defective autophagy machinery in the formation of α-synuclein aggregates, propagation of α-synuclein, and the resulting neurodegenerative processes in α-synucleinopathies.

Capacity constraints as a trigger for high growth

High-growth enterprises (HGEs) have a large economic impact but are notoriously hard to predict. Previous research has linked high-growth episodes to the configuration of lumpy indivisible resources inside firms, such that high capacity utilisation levels might stimulate future growth. We theorize that firms reaching critically high capacity utilisation levels reach a “trigger point” involving either broad-based investment in further growth or shrinking back to previous levels. We analyze EIBIS survey data (matched to ORBIS) which features a question on time-varying capacity utilisation. Overcapacity is a transitory state. Firms enter into overcapacity after a period of the rapid growth of sales and profits, and the years surrounding overcapacity have higher employment growth rates. Firms operating at overcapacity make incremental investments (e.g. capacity expansion, process improvements and modern machinery) rather than investing in R&D and new product development. We find support for the “fork in the road” hypothesis: for some firms, overcapacity is associated with launching into massive investments and subsequent sales growth, while for other firms, overcapacity is negatively related to both investments and sales growth.

Evaluate the Immediate Effect of High- power Pain Threshold Ultrasound on Treatment of Upper Trapezius Active Myofascial Trigger Points

Introduction: The most critical clinical presentation in myofascial pain syndrome is trigger points. Trigger points are the main problem in 30% of the patients presenting to general internal medicine practice. One of the treatments used for trigger points is ultrasound therapy. The high- power pain threshold ultrasound (HPPTUS) technique is one of the therapeutic ultrasound modifications used to treat trigger points. The present randomized clinical trial aimed to investigate the immediate effect of high-power pain threshold ultrasound on treating active trigger points of the upper trapezius muscle in men with mechanical neck pain. Materials and Methods: Fourteen men with mechanical neck pain (Mean±SD age: 34.50±5.24 years) who met the inclusion and exclusion criteria participated in this study. The visual analog scale (VAS), pressure pain threshold (PPT), and range of motion of cervical lateral flexion (CLF) were assessed before and after the treatment. The ultrasound probe was placed on the trigger point. The frequency was set to 1 MHz, and the intensity increased from 0.5 to 2 until the patient reported an unpleasant sensation. The probe was held there for 4 seconds. Then, the intensity was reduced by 50%, and the probe was moved over and around the trigger point. This process was done several times for three minutes. Results: Analysis of pre-treatment and post-treatment findings showed that the VAS (P<0.001), PPT (P=0.001), and CLF (P<0.001) improved significantly after applying the HPPTUS to trigger points. Conclusion: Ultrasound significantly improved the muscular symptoms of the trigger points.