1. Introduction
The specific objective of this review is to describe the elements of myofascial dysfunction particularly as they relate to visceral disease of the pelvis and how the awareness of myofascial dysfunction might affect the management of certain visceral diseases by the procedure of laparoscopy. The specific areas to be reviewed are among the most common gynecological conditions – chronic pelvic pain and endometriosis.
Although diagnostic and operative laparoscopy has brought about significant improvements to women’s health, there is growing concern that this procedure might be over-utilized. Increased rates of the procedure may influence the health of women in a deleterious manner as there are significant complications associated with the procedure. This is then a cautionary chapter that seeks to provide the clinician with tools to appreciate the presence of myofascial dysfunction and its ramifications.
2. Case history
Miss C.M. is a 24 year old woman who presents with the development of severe chronic pelvic pain in the right and left lower quadrant of the abdomen for approximately one year. The pain began as a cyclic pain which resulted in an operative laparoscopy during which she had a number of areas of endometriosis cauterized in the
At the second opinion, the examination demonstrated
This chapter is directed to an evaluation of this common clinical situation.
3. Benefits of laparoscopy
Diagnostic and operative laparoscopy has added significantly to the management of many surgical conditions1-4. These have extended to improved management of certain gynecological conditions 5-7. In addition to diagnosis, laparoscopy has evolved to more invasive procedures to include ovarian cystectomy, oophorectomy, assisted hysterectomy, total hysterectomy, radical hysterectomy and pelvic and paraaortic lymph node dissection 8-15. There is general acceptance that the procedure has immense benefits for the management of acute pain conditions such as those related to the management of ovarian torsion, ovarian cyst hemorrhage and the diagnosis of pelvic inflammatory disease16-18. Laparoscopic surgery has resulted in reduced hospital admissions, and operating time thereby increasing efficiencies in health service provision19;20.
4. Laparoscopy for chronic pelvic pain
Although marked benefits for some conditions are substantial the same cannot be said for its use in the diagnosis and treatment of chronic pelvic pain. This condition is very common among women and is responsible for significant disability and personal suffering21. Much of the distress of the condition is associated with a difficulty in “being believed”. The condition is defined as pain in the abdomen, pelvis or lower back lasting six months. However, the concept that there is an operational definition for the condition has been challenged22. The absence of a pattern that permits categorization of the condition in terms of pain duration, location, co morbidities has been identified as a barrier to appropriate research 22.
Despite this important limitation, there have been a large number of studies with a variety of results that have explored the relationship of chronic pelvic pain and laparoscopy. In some cases, the benefits have been identified as the diagnosis of chronic pelvic inflammatory disease. Although often not noted, these benefits seem to be associated with the first laparoscopy23-28. More recently, reports have indicated that the ability to identify a pathological condition are not as high as previously reported29. It has been estimated that 25-40% of women having laparoscopies for chronic pain conditions do not have a reliable diagnosis identified29;30. Among the identifiable conditions associated with chronic pelvic pain, one condition is readily identified as a potential cause in 65% of cases and one third of these will have endometriosis31. Additional causes identified are reported to be pelvic inflammatory disease, ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, post-operative peritoneal inclusion cysts and endosalpingeosis31. The remainder appears to have no obvious cause of the pain and can extend to a total of 40% of cases. These “negative” procedures are often quite upsetting to patients looking for a specific problem that can be solved in the manner associated with the treatment of acute illness.
5. Laparoscopy for endometriosis
One of the major indications in gynecology for diagnosis and treatment through the means of laparoscopy is directed to the management of endometriosis32. Space does not permit a comprehensive review of this condition but a brief summary will introduce its relationship to laparoscopy and myofascial dysfunction33-35. Endometriosis is a developmental abnormality in which there is endometrium-like tissue in ectopic locations of the pelvis and rarely in other areas of the body and requires pathological review for the confirmations of diagnosis36. It has been reported that the disease can occur in any area of the body with the exception of the spleen. The condition is associated with pain and infertility although these associations are not always present. In some cases of severe disease, there is no pain whatsoever while in other women, small amounts of endometriosis are associated with severe pain and disability37. Also, the presence of endometriosis does not preclude infertility as the disease is not uncommonly identified at the time of sterilization38. The condition is common and is seen in approximately 15% of women in the reproductive age group. It is increasingly being recognized in adolescents and appears to decrease after the menopause although here are exceptions to this.
Although there is a classification of the stages of endometriosis by the American Fertility Society, this classification is seen as helpful in the area of fertility but of a lesser benefit to pain considerations39;40. More recently the disease is classified with respect to four categories: peritoneal in location, nodular and invasive, ovarian endometriomas and uterine adenomyosis41-44. This latter condition represents a developmental abnormality in which the abnormal endometrial location is within the actual wall of the uterus. The epidemiology of the condition indicates risk factors to be delayed pregnancy, pelvic pain, pelvic mass, early menarche and frequent menses43;45-47.
Pain from endometriosis has been largely associated with the ectopic endometrium40. This tissue produces agents that can stimulate nocicepetive pain and drugs that inhibit inflammatory activity are often of benefit. The traditional approach to specific therapy has been to reduce estrogen as it stimulates the growth of the tissue. From a medical therapeutic perspective this has involved the use of progesterone, danazol and GnRH agonists that result in an ovarian suppression and a reduction in ovarian estrogen release48.
Prior to laparoscopy the surgical approach meant removal of the ovaries and uterus often in young women thereby eliminating their fertility. In recent years laparoscopy has afforded another approach. The operative removal of endometriosis at the time of laparoscopy has remained controversial. There has been several randomized controlled trial of the excision of endometriosis compared to sham surgery during operative laparoscopy. This approach was heralded as a highly effective prior to the randomized trials49. The randomized studies vary in terms of pain assessment and tend to be small in size and in some cases there is evidence of effectiveness 50;51. In another study, pain was measured during the entire menstrual cycle and was tested prior to and quarterly post-operatively for a year and there was no difference in pain between the excision group and the sham operated group. Most of the cases had early disease, identified as stage 1 or 2 by the American Fertility Society and peritoneal in location. Long term follow- up of the study indicated there was no difference in the time to the next operation undertaken for pelvic pain by survival analysis53. One of the interesting features was the observation that the level of pain from the first Pre-operative assessment predicted the time of subsequent surgery. Although this might seem self evident it has not been reported previously. In relation to the excision of endometriomas of the ovary, there is evidence of effectiveness54
There is a growing concern that the operations undertaken for endometriosis are not directed to the actual problem of pain55. This has been reviewed from the perspective of the limitations of surgery recently56. Also, there are recent reports that indicate the source of the pain which has been assumed to be the ectopic sites of endometriosis may in fact not represent the sole source of the pain33;57. The data that raise these concerns can be summarized as follows:
In addition to these studies of pain physiology, there is evidence from clinical utilization studies that operative laparoscopy is heavily used in the management of problems associated with endometriosis and adhesions. A review of the diagnostic and operative laparoscopies was undertaken in the Province of Alberta, Canada between the years 1994 and 200758. The data were collected on individual women over these years so that the frequency of repeated surgery on one woman could be assessed and then aggregated for the span of the study. The results indicated there was a significant repeat rate of surgery among 24,473 women (Figure 2). In addition, a statistical process control chart indicated the repeat rates were out of statistical control for both diagnostic and operative procedures for the years 1999-2000 (Figure 3)59. The interpretation is that there was a bias to operate during these years as it is highly unlikely that there was a sudden change in the rate of disease. Also, as there is a cut off in this study by the years 1999 and 2007 it is recognized these rates are limited as some women would have had procedures before and after these dates.
6. Myofascial dysfunction
Pain associated with muscle and fascia actually has a long history, going back to the seminal work of Sir Henry Head who recognized there were tender areas on the skin that consistently appeared in relation to disorders of the underlying viscera61. He called these Head zones and they were the basis for the recognition of the dermatomes. More recently these areas of pain were associated with both injury and trauma and were called trigger points. These are small areas of persistent contracture of muscle fibers that can cause severe pain and disability but are not generally appreciated among medical specialties with the exception of rehabilitation medicine. Since 1945 there have only been 1191 references in PubMed although there has been a significant increase in recent years. Recent reviews of myofascial pain and its relationship to trigger points have indicated the areas remains very complex62;63. Interest in the physiology of trigger points in relations to brain activity as well as muscle physiology is expanding64-67.
Myofascial pain syndrome is a muscle condition that has the characteristics of having local and referred pain originating in a myofascial trigger point68. This term describes a nodule or band of muscle that can produce intense pain when spontaneously or when stimulated. There are two aspects of the trigger point: a motor component that is palpable and a sensory component that produces pain locally and in an area of referred pain. The diagnosis of the presence of a trigger point is based on the palpation of a tender nodule or band that reproduces the patient’s symptoms and can be confirmed if there is a local twitch response as a result of manipulation of the taut band68. The pain is often referred to distant locations such as the back, chest or legs when considering pelvic trigger points.
Investigations of myofascial trigger points have focused on alterations in the synaptic cleft of the neuromuscular junction, the spinal cord and the brain response to myofascial pain68-70. The trigger point has been characterized as a local area of sensory and motor activity. The motor activity is based on the presence of the nodule or taut band. The area not maintained by persistent a motor activity as there are no motor action potentials present. Instead there are a variety of altered electrical observation that can be made including spontaneous small voltage activity, and spike discharges71. More recent studies have indicated that electrophysiological responses are commonly found when an electrode is placed in the trigger point for therapy72. There are also evoked changes in electrical activity in association with the local twitch response. These changes are not eliminated by an upper cord transaction indicating there is a spinal arc involved in their maintenance. Spontaneous discharges fropm a trigger point in the rabbit can be inhibited with phentolamine, an a blocker indicating the potential role of the sympathetic nervous system in the maintenance of these electrical discharges73.
The sensory component of the trigger point is based on changes in the intracellular environment. There is an increased synaptic level of acetylcholine activity, local ischemia as evidenced by biochemical changes of a lowered pH, and an increased concentration of Substance P, CGRP, bradykinin, serotonin, prostaglandins and potassium74. These areas act to stimulate nociceptors that are present in muscle tissue. Local ischemia has been identified as the cause of pain and is a result of the metabolic crisis that occurs in these areas.
Clinically the causes of myofascial trigger points have focused primarily on primary or secondary causes. The primary causes are identified as single or recurrent episodes of micro or macrotrauma or from muscle overload75. Overuse, postural stress and altered mechanics can produce trigger points in the neck and back. Secondary causes have included cervical whiplash, migraine headache, temporomandibular pain, frozen shoulder, radicular pain, postlaminectomy syndrome and viscero-somatic pain76. This chapter is directed to the application of the secondary trigger points associated with disorders of the viscera that produce pain.
7. Visceral causes of myofascial pain
There are a number of conditions that have resulted in myofascial trigger points. Diseases of the gall bladder have produced shoulder pain and trigger points in the right upper quadrant of the abdomen. Angina-like pain can be produced on the chest from cardiac ischemia and can lead to diagnostic confusion. Flank pain and trigger points can be produced by ureterolithiasis. One of the characteristics of these trigger points is that they may dissipate after the original condition has resolved but they may also remain for significant periods of time77;78.
The most common cause of myofascial pain has been trauma but in recent years there is an appreciation that visceral disease can produce somatic muscle pain and myofascial trigger points79;80. Examples in which there is an interaction of the viscera with somatic tissues include somatic hyperalgesia81;82, trophic changes in tissue83;84. In the rat, intense stimulation of the intrauterine cavity is associated with neurogenic extravasation of administered dye in the region of the dermatomes innervating the pelvic85. In visceral pain as well as migraine, there are reports that in addition to myofascial trigger points, there is a development of cutaneous allodynia in the respective dermatomal regions86;87.
On important aspect of the physiology of viscero-somatic pain referral has been undertaken in relation to the gall bladder. Diseases of the gall bladder were found to produce changes in pain thresholds in the skin, subcutaneous tissues and muscle, reduction in muscle thickness and cutaneous allodynia on the side of the gall bladder when compared to the contralateral side83. There was a direct negative correlation between the number of colicky aspects and the measurement of pain threshold.
These findings are also relevant in relation to the pelvis. The pelvic viscera include the uterus, ovaries, Fallopian tubes, pelvic peritoneum, bladder and rectum. Disorders such as endometriosis can potentially affect all of these structures. Disorders such as interstitial cystitis and irritable bowel syndrome are also disorders that affect the visceral tissues. It is now known the viscera contain nociceptors. It is now being recognized that visceral pain is a specific syndrome associated with alterations in the pelvic structures 88. As an example of human research related to visceral pain, the administration of capsaicin, an activator of the heat sensitive receptor TRPV189 to the intestinal stomata of volunteers with ileostomy or colostomy resulted in dramatic changes in the referral of pain and the temperature of the same areas of skin90.
8. Visceral pain in the pelvis
These changes have been studied in the abdomen and pelvis of women with chronic pelvic pain. A cross-sectional study of women with chronic pelvic pain for at least six months was done that included an assessment of the number of areas of myofascial pain, including the abdomen, perineum,
It is recognize that the diagnosis of chronic pelvic pain can be very misleading22. To attempt to partially address this, a cross-sectional study of bedside testing of
Briefly,
A test for myofascial dysfunction involves the palpation of a myofascial trigger point that is usually located within the area of
The identification of reduced pain thresholds was undertaken using the Von Fry Anesthesiometer95;96. This instrument has a variety of threshold adaptors but for these tests a 90 gram threshold was selected. Women were tested for pain in the deltoid muscle as an internal control for central pain an then in the right and left upper quadrant, right and left lower quadrants and the perineal body for a measure of intra-pelvic sensitivity.
The results of these tests indicate at least on a preliminary basis, an ability to differentiate women with pre-existing or concurrent visceral disease from women without such a condition. The most significant test to be undertaken was the simple use of a cotton-tipped applicator, a device that is available in every clinician’s office. Although the discrimination of these groups may not be perfect, it is an approach that is recognizable from clinicians.
The clinical importance of these preliminary findings is that they may identify an important potential confounder in the clinical determination of the cause of pain, particularly the recurrent pain associated with women presenting with recurrent pain following operative laparoscopy. It is entirely possible that the reasons for many of the “negative” laparoscopies associated with chronic pelvic pain may be due to high frequencies of myofascial dysfunction. Traditionally, clinicians have been trained in gynecology to undertake a clinical examination for a pelvic mass. The bimanual examination is one that places a lot of stress on the abdominal wall exactly over the most common areas of trigger points. It also places a great deal of pressure on the perineum and the vaginal barrel that is the product of the tone of the
Briefly in the evaluation of a woman with chronic pelvic pain, the presence of
9. Alternatives to laparoscopy
Women with chronic pelvic pain will benefit from multidisciplinary care. There is Level 1 Evidence of its effectiveness. The approach is based on the shift from the traditional acute medical model directed to a “cure” to the recognition that cures in chronic pain are extremely rare and the more appropriate approach is to manage pain in a rehabilitative sense. The elements of such rehabilitation are first and foremost education in the change in concept that is not always accepted by the woman seeking care. Women who seek the cure at all costs have been identifies as pre-contemplative to the rehabilitative model and unlikely to benefit from this type of management. Similarly catastrophic thinking or approaches to the pain have been recognized as risk factors for failure. In addition to education, cognitive behavioral therapy has Level 1 Evidence of effectiveness. This involves self monitoring of pain, pacing activities carefully and ensuring a restorative sleep pattern is possible. Smoking is strongly discouraged.
Myofascial pain is often effectively managed by physiotherapy self exercise and muscle injections with local anesthetic or botulinum toxin97. One must be cautious in the use of botulinum toxin in the abdomen as cases of its migration into the hip casuing temporary difficulties in ambulation have occurred. It is highly effective however in the perineum where it improves aspects of sexual function. Use in the
Management also assists at times with pain relief that some times requires opiate medication to permit a reduction in hyperalgesia to allow physiotherapists access to areas of myofascial tenderness. Psychological assessment is critical in the approaches to managing stress and the early detection of depression that occurs in approximately 50% of women with chronic pain. Depression is an important barrier to clinical improvement100. Occupational therapy is involved in the assessment of capability in working and ergonomic assessments of the worksites101. One of key concepts is the development of self directed management of pain102. Group therapy can be extremely beneficial in providing access to approaches to intimacy for women who have sexual pain103. Groups directed to generating pelvic muscle stretch and strengthening of core muscles are also beneficial104.
10. Summary
While laparoscopy has demonstrative evidence of effectiveness in many situations, its position in relation to chronic conditions requires additional consideration. Viscero-somatic pain referral is very common. It can be identified in association with endometriosis, pelvic inflammatory disease and other pelvic visceral diseases. It can be identified with simple bedside tests, the most helpful being the recognition of cutaneous allodynia with a simple culture stick. Its recognition help to identify alternative mechanisms of pain and potentially reduced unnecessary surgery.
References
- 1.
no.Young-Fadok T. M. et al. Benefits . of-Assisted Laparoscopic. Colectomy for. Colon Polyps. a. Case-Matched Series. Mayo Clin. Proc 4 2000 2000 344 348 - 2.
no.Smith J. F. et al. Risks . Benefits of. Laparoscopic Cholecystectomy. in the. Community Hospital. Setting Laparoendosc J. Surg 6 1991 1991 325 332 - 3.
Schwenk W. et al. Short . Term Benefits. for Laparoscopic. Colorectal Resection. Cochrane Database. Syst Rev. no 2005 CD003145 EOF - 4.
Memon M. A. Fitzgibbons R. J. Jr Assessing . Risks Costs. Benefits of. Laparoscopic Hernia. Repair Annu Rev. Med . 1998 95 EOF 109 EOF - 5.
Mais V. et al. Laparoscopic . Versus Abdominal. Myomectomy a. Prospective Randomized. Trial to. Evaluate Benefits. in Early. Outcome Am J. Obstet Gynecol. 17 no 2 1996 1996 654 658 - 6.
no.Garry R. The . Benefits Problems Associated. With Minimal. Access Surgery. Aust N. Z. J. Obstet Gynaecol. 3 2002 2002 239 244 - 7.
no.Dueholm S. Zingenberg H. Sandgren G. "[ The. Risks Benefits of. Laparoscopic Sterilization]. Ugeskr Laeger. 14 no 47 1985 1985 3780 3783 - 8.
no.Zullo F. et al. Minilaparoscopic . Ovarian Drilling. Under Local. Anesthesia in. Patients With. Polycystic Ovary. Syndrome Fertil Steril. 2 2000 2000 376 379 - 9.
no.Yuen P. M. et al. Randomized . A. Prospective Study. of Laparoscopy. Laparotomy in. the Management. of Benign. Ovarian Masses. Am J. Obstet Gynecol. 17 no 1 1997 1997 109 114 - 10.
Schollmeyer T. et al. Chronic . Isolated Torsion. of the. Left Fallopian. Tube a. Diagnostic Dilemma. Arch Gynecol. Obstet 27. no 1 2008 2008 87 90 - 11.
no.Cheng M. H. et al. Laparoscopic . Plication of. Partially Twisted. Ovary With. Massive Ovarian. Edema Chin J. Med Assoc 5 2006 2006 236 239 - 12.
no.Sadik S. Uran B. Ozaydin T. Laparoscopic-Assisted . Vaginal Hysterectomy. Bilateral-Oophorectomy Salpingo. With Suturing. Technique Am J. Assoc Gynecol. Laparosc 4 1995 1995 437 440 - 13.
no.Liang J. T. et al. Laparoscopic . Prophylactic Oophorectomy. Plus N. Lymphadenectomy for. Advanced Rectosigmoid. Cancer Ann Surg. Oncol 7 2007 2007 1991 1999 - 14.
Puntambekar S. P. et al. Laparoscopic . Total Radical. Hysterectomy by. the Pune. Technique Our. Experience of. 2. Cases Minim J. Invasive Gynecol. 1. no 6 2007 2007 682 689 - 15.
Malzoni M. et al. Feasibility . Morbidity Safety of. Total Laparoscopic. Radical Hysterectomy. With Lymphadenectomy. Our Experience. Minim J. Invasive Gynecol. 1. no 5 2007 2007 584 590 - 16.
no.Augustin G. Majerovic M. Non-Obstetrical . Acute Abdomen. During Pregnancy. Eur J. Obstet Gynecol. Reprod Biol. 1 2007 2007 4 12 - 17.
Year-Old Girl," 33, no.Goktolga U. et al. Isolated . Torsion of. Fallopian Tube. in a. Premenarcheal 1. Year-Old Girl. Obstet J. Gynaecol Res. 3. no 2 2007 2007 215 217 - 18.
no.Oji I. Kitching A. Smith K. Severe . Acute Pain. Following Application. of Filshie. Clips a. Case of. Possible-Visceral Viscero. Sensitization Obstet J. Gynaecol 4 2005 2005 400 401 - 19.
no.Gagne J. P. et al. Advanced . Laparoscopic Surgery. in a. Free-Standing Ambulatory. Setting Lessons. From the. First . Cases Surg Innov. 1 2007 2007 12 17 - 20.
Gaitan H. G. Eslava-Schmalbach J. Gomez P. I. Cost . Effectiveness of. Diagnostic Laparoscopy. in Reproductive. Aged Females. Suffering From. Non-Specific Acute. Low Abdominal. Pain Rev Salud. Publica . Bogota . no 2 2005 2005 166 179 - 21.
no.Zondervan K. Barlow D. H. Epidemiology . of Chronic. Pelvic Pain. Baillieres Best. Pract Res. Clin Obstet. Gynaecol 3 2000 2000 403 414 - 22.
no.Williams R. E. Hartmann K. E. Steege J. F. Documenting . the Current. Definitions of. Chronic Pelvic. Pain Implications. for Research. Obstet Gynecol. 4 2004 2004 686 691 - 23.
Lira S. Carranza et. al "[ The. Laparoscopic Findings. in Patients. With Chronic. Pelvic Pain. Dysmenorrhea] Ginecol Obstet. Mex 62 1994 1994 82 84 - 24.
Vercellini P. et al. Laparoscopy . in the. Diagnosis of. Chronic Pelvic. Pain in. Adolescent Women. Reprod J. Med 3. no 10 1989 1989 827 830 - 25.
Apropos of 184 Cases]," 13, no.Priou G. et al. "[ The. Diagnostic Value. of Celioscopy. in the. Evaluation of. Chronic Pelvic. Pain 4 1984 1984 395 402 - 26.
Kresch A. J. et al. Laparoscopy . in 1. Women With. Chronic Pelvic. Pain Obstet Gynecol. 6. no 5 1984 1984 672 674 - 27.
Redecha M. et al. "[ Laparoscopic. Findings in. Women With. Chronic Pelvic. Pain] Bratisl Lek. Listy 10. no 8 2000 2000 460 464 - 28.
no.Bahary C. M. Gorodeski I. G. The . Diagnostic Value. of Laparoscopy. in Women. With Chronic. Pelvic Pain. Am Surg. 11 1987 1987 672 674 - 29.
Suppl (Newham A. P. van der Spuy Z. M. Nugent F. Laparoscopic . Findings in. Women With. Chronic Pelvic. Pain Afr S. Med J. 8. no 1996 1200 EOF 3 EOF - 30.
no.Howard F. M. The . Role of. Laparoscopy in. the Chronic. Pelvic Pain. Patient Clin Obstet. Gynecol 4. no 4 2003 2003 749 766 - 31.
no.Howard F. M. The . Role of. As Laparoscopy a. Diagnostic Tool. in Chronic. Pelvic Pain. Baillieres Best. Pract Res. Clin Obstet. Gynaecol 3 2000 2000 467 494 - 32.
no.Eltabbakh G. H. Bower N. A. Laparoscopic . Surgery in. Endometriosis Minerva Ginecol. 4 2008 2008 323 330 - 33.
no.Reiter R. C. Gambone J. C. Nongynecologic . Somatic Pathology. in Women. With Chronic. Pelvic Pain. Negative Laparoscopy. Reprod J. Med 4 1991 1991 253 259 - 34.
no.Carter J. E. Systematic . A. History for. the Patient. With Chronic. Pelvic Pain. J. S. L. S. 4 1999 1999 245 252 - 35.
no.Jarrell J. F. The . Weight of. Chronic Pelvic. Pain Obstet J. Gynaecol Can. 5 2004 2004 453 456 - 36.
no.Marchino G. L. et al. Diagnosis . of Pelvic. Endometriosis With. Use of. Macroscopic Versus. Histologic Findings. Fertil Steril. 1 2005 2005 12 15 - 37.
Chatman D. L. Zbella E. A. Biopsy . in Laparoscopically. Diagnosed Endometriosis. Reprod J. Med 3. no 11 1987 1987 855 857 - 38.
no.Vercellini P. Bocciolone L. Crosignani P. G. Is . Mild Endometriosis. Always a. Disease? Hum Reprod. 5 1992 1992 627 629 - 39.
Canis M. et al. Classification . of Endometriosis. Baillieres Clin. Obstet Gynaecol. . no . 1993 759 EOF 74 EOF - 40.
Howard F. M. Endometriosis . Mechanisms of. Pelvic Pain. Minim J. Invasive Gynecol. . 2009 540 EOF 550 EOF - 41.
no.Brosens I. Donnez J. Benagiano G. Improving . the Classification. of Endometriosis. Hum Reprod. 11 1993 1993 1792 1795 - 42.
no.Chapron C. et al. Deeply . Infiltrating Endometriosis. Pathogenetic Implications. of the. Anatomical Distribution. Hum Reprod. 7 2006 2006 1839 1845 - 43.
Liu X. et al. Patterns . of Risk Factors. for Recurrence. in Women. With Ovarian. Endometriomas Obstet Gynecol. 10 no 6 2007 2007 1411 1420 - 44.
no.Yeniel O. et al. Adenomyosis . Prevalence Risk. Factors Symptoms. Clinical Findings. Clin Exp. Obstet Gynecol. 3. no 3 2007 2007 163 167 - 45.
Guo S. W. Wang Y. The . Prevalence of. Endometriosis in. Women With. Chronic Pelvic. Pain Gynecol Obstet. Invest 6. no 3 2006 2006 121 130 - 46.
N. Sinaii et al., "Differences in Characteristics Among 1,000 Women With Endometriosis Based on Extent of Disease," ( 2007 ). - 47.
no.Moen M. H. Schei B. Epidemiology . of Endometriosis. in a. Norwegian County. Acta Obstet. Gynecol Scand. 6 1997 1997 559 562 - 48.
Surrey E. S. The . Role of. Progestins in. Treating the. Pain of. Endometriosis Minim J. Invasive Gynecol. 1. no 6 2006 2006 528 534 - 49.
no.Redwine D. B. Remote . Recollection of. Preoperative Pain. in Patients. Undergoing Excision. of Endometriosis. Am J. Assoc Gynecol. Laparosc 2 1994 1994 140 145 - 50.
no.Sutton C. J. et al. Prospective . Randomized-Blind Double. Controlled Trial. of Laser. Laparoscopy in. the Treatment. of Pelvic. Pain Associated. With Minimal. Mild Moderate Endometriosis. Fertil Steril. 4 1994 1994 696 700 - 51.
no.Jones K. D. Haines P. Sutton C. J. Long-Term . Follow-Up of. a. Controlled Trial. of Laser. Laparoscopy for. Pelvic Pain. J. S. L. S. 2 2001 2001 111 115 - 52.
no.Jarrell J. et al. Laparoscopy . Reported Pain. Among Patients. With Endometriosis. Obstet J. Gynaecol Can. 5 2005 2005 477 485 - 53.
J Jarrell et al., "Women’s Pain Experience Predicts Future Surgery for Pain Associated With Endometriosis," in press ( 2008 ). - 54.
no.Hart R. et al. Excisional . Surgery Versus. Ablative Surgery. for Ovarian. Endometriomata a. Cochrane Review. Hum Reprod. 11 2005 2005 3000 3007 - 55.
P. Stratton and K. J. Berkley, "Chronic Pelvic Pain and Endometriosis: Translational Evidence of the Relationship and Implications," ( 2010 ). - 56.
no.Vercellini P. et al. The . Effect of. Surgery for. Symptomatic Endoometriosis:the. Other Side. of the. Story Hum Reprod. Update 2 2009 2009 177 188 - 57.
MLS Montenegro et. al Abdominal . Myofascial Pain. Syndrome Must. Be Considered. in the. Differential Diagnosis. of Chronic. Pelvic Pain. Europ J. Obstet Gynecol. Repr Biol. 1. 2009 - 58.
Jarrell J. Diagnostic . Operative Laparoscopy. in Alberta. 1994 2006 accepted J. O. G. C. 2008 - 59.
no.Jarrell J. Annual . Repeat Laparoscopic. Surgery A. Marker of. Practice Variation. Medical A. M. J. Quality 2. no 5 2009 2009 378 383 - 60.
no.Jarrell J. Diagnostic . Operative Laparoscopy. in Alberta. 1994-2006 Obstet J. Gynaecol Can. 11 2008 2008 1045 1049 - 61.
Head H. . On Disturbances. of Sensation. With Especial. Reference to. the Pain. of Visceral. Disease Brain . 2010 339 EOF 276 EOF - 62.
I): Epidemiology, Clinical Treatment and Etiopathogeny," 14,Vazquez-Delgado E. Cascos-Romero J. Gay-Escoda C. Myofascial . Pain Syndrome. Associated With. Trigger Points. a. Literature Review. . 10 2009 e494 e498. - 63.
Part 2: Differential Diagnosis and Treatment," (Vazquez-Delgado E. Cascos-Romero J. Gay-Escoda C. Myofascial . Pain Associated. to Trigger. Points A. Literature Review. 2010 - 64.
no.Niddam D. M. Brain . Manifestation Modulation of. Pain From. Myofascial Trigger. Points Curr Pain. Headache Rep. 5 2009 2009 370 375 - 65.
no.Simons D. G. New . Views of. Myofascial Trigger. Points Etiology. Diagnosis Arch Phys. Med Rehabil 1 2008 2008 157 159 - 66.
no.Shah J. P. Gilliams E. A. Uncovering . the Biochemical. Milieu of. Myofascial Trigger. Points Using. in Vivo. Microdialysis an. Application of. Muscle Pain. Concepts to. Myofascial Pain. Syndrome Bodyw J. Mov Ther. 4 2008 2008 371 384 - 67.
no.Shah J. P. et al. Biochemicals . Associated With. Pain Inflammation Are. Elevated in. Sites Near. to Remote From. Active Myofascial. Trigger Points. Arch Phys. Med Rehabil 1 2008 2008 16 23 - 68.
no.Gerwin R. D. Dommerholt J. Shah J. P. An . Expansion of. Simons’ Integrated. Hypothesis of. Trigger Point. Formation Curr Pain. Headache Rep. 6 2004 2004 468 475 - 69.
no.Kuan T. S. Current . Studies on. Myofascial Pain. Syndrome Curr Pain. Headache Rep. 5 2009 2009 365 369 - 70.
no.Niddam D. M. Brain . Manifestation Modulation of. Pain From. Myofascial Trigger. Points Curr Pain. Headache Rep. 5 2009 2009 370 375 - 71.
no.Hong C. Z. Simons D. G. Pathophysiologic . Electrophysiologic Mechanisms. of Myofascial. Trigger Points. Arch Phys. Med Rehabil 7. no 7 1998 1998 863 872 - 72.
no.Rivner M. H. The . Neurophysiology of. Myofascial Pain. Syndrome Curr Pain. Headache Rep. 5 2001 2001 432 440 - 73.
no.Chen J. T. et al. Phentolamine . Effect on. the Spontaneous. Electrical Activity. of Active. Loci in. a. Myofascial Trigger. Spot of. Rabbit Skeletal. Muscle Arch Phys. Med Rehabil 7. no 7 1998 1998 790 794 - 74.
no.Shah J. P. et al. Biochemicals . Associated With. Pain Inflammation Are. Elevated in. Sites Near. to Remote From. Active Myofascial. Trigger Points. Arch Phys. Med Rehabil 1 2008 2008 16 23 - 75.
no.Wheeler A. H. Aaron G. W. Muscle . Pain Due. to Injury. Curr Pain. Headache Rep. 5 2001 2001 441 446 - 76.
no.Gerwin R. D. Classification . Epidemiology Natural History. of Myofascial. Pain Syndrome. Curr Pain. Headache Rep. 5 2001 2001 412 420 - 77.
Vecchiet L. Vecchiet J. Giamberardino M. A. Referred . Muscle Pain. Clinical Pathophysiologic Aspects. Curr Rev. Pain . no 6 1999 1999 489 498 - 78.
Vecchiet L. Giamberardino M. A. Referred . muscle pain. hyperalgesia from. viscera in Muscle. Pain Myofascial. Pain Fibromyalgia . New York. N. Y. Haworth Medical. press 1999 61 EOF 69 EOF - 79.
Vecchiet L. Vecchiet J. Giamberardino M. A. Referred . Muscle Pain. Clinical Pathophysiologic Aspects. Curr Rev. Pain . no 6 1999 1999 489 498 - 80.
Vecchiet L. Vecchiet J. Giamberardino M. A. Referred . Muscle Pain. Clinical Pathophysiologic Aspects. Curr Rev. Pain . no 6 1999 1999 489 498 - 81.
no.Stawowy M. et al. Somatosensory . Changes in. the Referred. Pain Area. in Patients. With Acute. Cholecystitis Before. After Treatment. With Laparoscopic. or Open. Cholecystectomy Scand J. Gastroenterol 10 2004 2004 988 993 - 82.
Giamberardino M. A. Recent . Forgotten Aspects. of Visceral. Pain Eur J. Pain . no 2 1999 1999 77 92 - 83.
Giamberardino M. A. et al. Relationship . Between Pain. Symptoms Referred Sensory. Trophic Changes. in Patients. With Gallbladder. Pathology Pain 11. no 2005 239 EOF 49 EOF - 84.
Procacci P. Zoppi M. Maresca M. Clinical . Approach to. Visceral Sensation. Prog Brain. Res . 1986 21 EOF 8 EOF - 85.
no.Wesselmann U. Lai J. Mechanisms . of Referred. Visceral Pain. Uterine Inflammation. in the. Adult Virgin. Rat Results. in Neurogenic. Plasma Extravasation. in the. Skin Pain 7. no 3 1997 1997 309 317 - 86.
Bevilaqua-Grossi D. et al. Temporomandibular . Disorders Cutaneous Allodynia. Are Associated. in Individuals. With Migraine. Cephalalgia 3. no 4 2010 2010 425 432 - 87.
no.Janig W. Habler H. J. "[ Physiology. Pathophysiology of. Visceral Pain]. Schmerz 6 2002 2002 429 446 - 88.
no.Wesselmann U. Neurogenic . Inflammation Chronic Pelvic. Pain World J. Urol 3 2001 2001 180 185 - 89.
Drewes A. M. et al. Gut . Pain Hyperalgesia Induced. by Capsaicin. a. Human Experimental. Model Pain 10. no 2003 333 EOF 41 EOF - 90.
L. Arendt-Nielsen et al., "Viscero-Somatic Reflexes in Referred Pain Areas Evoked by Capsaicin Stimulation of the Human Gut," ( 2007 ). - 91.
Jarrell J. . Gynecological Pain. Endometriosis Visceral. Disease the-Somatic Viscero. Connection Muscskel J. Health . 2008 21 EOF 27 EOF - 92.
Jarrell J. MA Giamberardino Robert M. . Bedside Tests. of-Somatic Viscero. Pain Obstetrics Gynecology Submitted. 2011 - 93.
Jarrell J, "Demonstration of Cutaneous Allodynia in Association With Chronic Pelvic Pain," (9 A.D.). - 94.
Fenton B. W. et al. Quantification . of Abdominal. Wall Pain. Using Pain. Pressure Threshold. Algometry in. Patients With. Chronic Pelvic. Pain Clin J. Pain 2. no 6 2009 2009 500 505 - 95.
Standard Values, Validity and Reproducibility of Pressure Threshold," 30, no.Fischer A. Pressure . Algometry Over. Normal Muscles. 1 1986 1986 115 126 - 96.
Cairns BE et al., "Glutamate-Induced Sensitization of Rat Masseter Muscle Fibers. Neuroscience," Neuroscience,2002 2002 109 2002 389 - 97.
no.Andres J. et al. Double-Blind . A. Controlled Randomized. Trial to. Evaluate the. Efficacy of. Botulinum Toxin. for the. Treatment of. Lumbar Myofascial. Pain in. Humans Reg Anesth. Med Pain 3. no 3 2010 2010 255 260 - 98.
no.Fraser H. M. et al. Long-Term . Suppression of. Ovarian Function. by a. Luteinizing-Hormone Releasing. Hormone Agonist. Implant in. Patients With. Endometriosis Fertil Steril. 1 1990 1990 61 68 - 99.
no.Vercellini P. et al. Comparison . of a. Levonorgestrel-Releasing Intrauterine. Device Versus. Expectant Management. After Conservative. Surgery for. Symptomatic Endometriosis. a. Pilot Study. Fertil Steril. 2 2003 2003 305 309 - 100.
no.Mirkin D. Murphy-Barron C. Iwasaki K. Actuarial . Analysis of. Private Payer. Administrative Claims. Data for. Women With. Endometriosis Manag J. Care Pharm. 3 2007 2007 262 272 - 101.
Preliminary Results of a Study on Health Staff of the Surgical Field]," 52, no.Fenga C. et al. "[ Chronic. Pelvic Pain. in Women. Prevalent Orthostatic. Work 3 2000 2000 69 72 - 102.
no.Glenn B. Burns J. W. Pain . Self-Management in. the Process. Outcome of. Multidisciplinary Treatment. of Chronic. Pain Evaluation. of a. Stage of. Change Model. Behav J. Med 5 2003 2003 417 433 - 103.
no.Breton A. Miller C. M. Fisher K. Enhancing . the Sexual. Function of. Women Living. With Chronic. Pain a. Cognitive-Behavioural Treatment. Group Pain Res. Manag 3 2008 2008 219 224 - 104.
Trampas A. et al. Clinical . Massage Modified Proprioceptive. Neuromuscular Facilitation. Stretching in. Males With. Latent Myofascial. Trigger Points. Phys Ther. Sport 1. no 3 2010 2010 91 98