‘The Biggest Health Scandal Affecting Women Since Thalidomide’ – Can Surgery to Remove Vaginal Mesh Reduce Severe Pain Following Failed Mesh Implants?

Feature Image of vaginal mesh sourced from:

https://news.sky.com/story/journalist-kath-sansom-was-wreck-after-vaginal-mesh-implant-11086123

Dear Pain Matters blog readers,

This blog post aims to offer hope, inspiration and courage to those women who suffer from severe and ongoing pelvic pain due to failed vaginal mesh implant surgery.

Pelvic mesh implant surgery was often recommended when conservative treatments for prolapse, incontinence and other pelvic conditions failed.

58f73dba1b0000330016c490.jpeg

Source:  Stocktrek images via Getty Images

https://www.huffingtonpost.co.uk/entry/what-is-vaginal-mesh-incontinence-treatment-risks_uk_58f71cdde4b05b9d613e6bda

Many women were ill-advised of the high risks associated with mesh implant surgery including severe and disabling pelvic pain.

In November 2017, the Therapeutic Goods Administration (TGA) in Australia finally banned 45 pelvic mesh devices including vaginally-implantable prolapse mesh devices and certain mesh slings following the international pelvic mesh fiasco (McCarthy, 2017).

For more information, please watch the 17-minute video by BBC News called ‘NHS sued over vaginal mesh implants’ (18 April 2017).

Several vaginal mesh victims including Kath Sansom (journalist, campaigner and founder of Sling the Mesh) and a urogynaecologist who specialises in mesh excisions are featured in this video. 

THREE (3) STUDIES OFFER GOOD NEWS FOR SOME FAILED MESH IMPLANT PATIENTS    

Overview

Patients suffering from severe pain and other serious complications due to failed mesh implants may explore whether mesh removal surgery (i.e. mesh excision) is a viable option to remove all or part of the mesh implant. 

http://www.med.umich.edu/1libr/Gyn/ExcisionOfMesh.pdf

https://urogyn.coloradowomenshealth.com/patients/library/transvaginal-mesh-removal

Three (3) mesh removal and/or suburethral tape removal studies, being American, French and Dutch studies, are discussed below:

An American Vaginal Mesh/Suburethral Tape Removal Study

An American study analyzed the results of 123 patients who had surgery to remove vaginal mesh (N=69; the mesh group) or synthetic suburethral tape (N=54; the tape group) in a bid to reduce pain during 2005 to 2013.

The average visual analog score (VAS) score was reduced from 7.9 (before surgery) to 0.9 after removal surgery in the mesh group, as revealed during follow-up 6 to 47 months later.

Meanwhile, the average VAS score decreased from 5.3 (pre-surgery) to 1.5 after removal surgery in the tape group, as revealed during follow-up 6 to 59 months later.

Best of all, 81% of the tape group and 67% of the mesh group were completely pain-free after their respective surgeries!    

The authors concluded that if pain is the only reason for surgery to remove either suburethral tape or vaginal mesh, it is likely then that significant pain relief will result following removal surgery (Hou et al, 2014).

A French Mesh Removal Study

A French mesh removal study revealed that mesh can be removed both safely and efficiently in many patients, with operating times averaging only 21 minutes.  (NB Some mesh removal operations may require several hours to perform.)

Specifically, 61 of 83 mesh patients underwent complete mesh removal.  Fifty-eight (58) mesh excisions were done more than 2 years after the mesh was implanted in the first place (Marcus-Braun and von Theobald, 2010).

A Dutch Mesh Excision Study

A Dutch study analysed 73 mesh-implanted patients who underwent partial or complete mesh excision.  Thirty (30) patients had complete mesh removal while 43 patients underwent 51 partial mesh operations.

Prior to their mesh removal surgery, 77% suffered severe pain including vaginal pain, vaginal bleeding/discharge, pain during sex as well as lower abdominal, back, buttock and/or leg pain.

Positive outcomes including symptom relief were achieved for 92% of the 73 patients.

Specifically, 70% of those patients who underwent complete mesh excision and 60% of those who had partial mesh excision enjoyed COMPLETE RELIEF from mesh-related symptoms.

As with all surgeries, there are inherent risks and complications that may be involved with mesh excisions.  Furthermore, pelvic organ prolapse or stress urinary incontinence may recur (Tijdink et al, 2011).

Further to Aforementioned 3 Studies 

Please note that whilst the results from the American, French and Dutch studies appear very encouraging, it is not known whether these results can be extrapolated and/or whether these results are representative of the norm.  More studies are required.*  

Each mesh victim who seeks medical advice regarding mesh excision surgery needs to be individually assessed by a highly skilled medical specialist and/or by a mesh removal medical centre (that may or may not be nearby).  

Whilst there is always hope, mesh removal surgery may not always be an option due to excessive risks and complications inherent in certain individuals.  

However, until one knows for sure, ‘it is usually better to look at the glass as being half full than half empty’.   

At the end of the day, botched mesh implants is a collective human issue, and not just an individual problem.  As such, we are all in this ‘mesh mess’ together … not just the mesh victims themselves.

Kath Sansom’s Story Including Removal of Vaginal Mesh Implant

Kath Sansom is a journalist and mom of two who used to enjoy high-board diving, boxing and mountain biking.

In March 2015, Kath had a vaginal mesh implant for mild stress urinary incontinence caused by childbirth.

skynews-kath-sampson-samson_4130940.jpg    Kath Sansom, journalist, campaigner and founder of Sling the Mesh

Source: https://news.sky.com/story/journalist-kath-sansom-was-wreck-after-vaginal-mesh-implant-11086123

As soon as her mesh sling was implanted, Kath felt pain. In her words,

‘The pain was instant. I struggled to walk. The pain down the backs of my legs felt like really deep, heavy toothache. It hurt me to walk, sit, lie. I couldn’t get any relief. I had cheese-wiring pains in my vagina, burning pain so bad I couldn’t even use a tampon. In the weeks before, I did a boxing class, high-board diving and mountain biking. I went from that to excruciating pain … it gradually got worse and worse.’

Kath felt betrayed because the true risks of vaginal mesh implants were never revealed to her prior to surgery.  She said she would have ‘run out the door’ if only someone had said (quoting),

‘You can have this little operation but you might lose your sex life.’

or

‘You can have this little operation and you might not be able to walk – but at least you won’t wee your pants.’  

Kath Sansom had her botched mesh sling removed 7 months later.  In her words (quoting),

‘I got a lot better, although I’m right up there at the good end of recovery compared with other women. I can still swim. But even so, it’s a new normal. I have to be very careful when putting impact on my legs, I have to be careful how I move. If I overdo things I can end up in pain the next day and having to take strong painkillers. I’ve got all these pain relievers in my bag just in case …’

‘You go from being a healthy mum with a bit of an embarrassing problem, to suddenly your life is turned on its head. And you’ve got to accept that this is now your life because even if you have a mesh removal, you will never go back to the woman you were.’

After her dreadful experience with the now-removed vaginal mesh implant, Kath founded and runs the Sling the Mesh campaign group that has over 7,300 members (Sansom, 2017; Brown, 2018; Sansom, 2018; Briggs, 2019; Sling the Mesh).

https://slingthemesh.wordpress.com

@MeshCampaign

Catie’s Story Including Removal of Mesh Implant

The following is a story about Catie in New Zealand who underwent 3 operations in an effort to remove all mesh.

Catie’s pelvic mesh was initially implanted without incident.  However, 2 years later, (quoting Catie) ‘[the mesh] was rotting and eroding inside …’, causing pain and discharge.  At first, Catie was treated for a potential STD (which wasn’t the case at all) via ‘many courses of metronidazole’, an antibiotic with terrible side effects.

Several years later in March 2011, Catie finally underwent her first mesh removal surgery.  The partial mesh excision took 5 hours because (in Catie’s words) ‘[the mesh] was so ‘stuck’ on in bits and the surgeon had a lot of difficulty getting it out’.

By August 2012, Catie had 2 more excision surgeries.

After her third (and hopefully final) excision surgery that involved ‘a good clean out’ and a D&C, (quoting Catie) ‘there [was] no revolting discharge and … no pain’.

In Catie’s view, it may be another year or more before she will have fully recovered.  She credits her mesh removal surgeon for being wonderful.

Formerly a triathlete, Catie is struggling to become active again.  Nonetheless she is grateful for feeling better after a very long and painful journey.

Catie’s Story:

http://meshdownunder.co.nz/kiwi-stories

WARNING – DO NOT UNDERGO RISKY MESH IMPLANT SURGERY

Many Patients Including an Australian Woman, Jan Wise, Suffer from Pain and Other Complications Following a Botched Mesh Implant 

ALL WOMEN, both young and young-at-heart, should be DISCOURAGED from undergoing surgical mesh implants in the first place.  Full stop.  End of story.

The high risks and serious complications can be catastrophic, post-mesh implant surgery.  Mesh implants can cause permanent, disabling and incapacitating pelvic injuries as well as severe, intractable pelvic pain.

Quoting Jan Wise (who now suffers from back and leg pain thanks to a botched implant surgery involving a pig intestine pelvic mesh device in 2012):

‘[I am] rotting from the inside … shooting electrical shock pain from my lower body up through to my head … hoping the thoughts of the nightmare won’t take up too much of [every] day. I allow myself only one period of sadness and crying per day’ (McCarthy, 2017).

Post-implant, in addition to severe pain, Jan suffers ongoing incontinence, a collapsed vagina, (quoting Jan) ‘putrid seroma discharge’ and ‘pelvic discharge with a foul smell’ as well as loss of intimacy with her husband.  In her words, It’s a dreadful mess down there.’

Some women require pain killers and benzodiazepines as well as regular catheterisation (due to a lost ability to urinate following a failed implant).  Many suffer chronic incontinence together with ongoing urinary tract and vaginal infections, discharge and granulomas.  Others require enemas for chronic bowel problems.  Punctures or lacerations of vessels, nerves, bladder, urethra, bowel, organs and other structures may occur.  Mesh implants often erode into the vagina rendering sex impossible with their husbands or partners.  

In some instances, exposed mesh may even cause pain and injury to the male partner during intercourse (McCarthy, 2017; Stern, 2017 – in German).

Sadly, the list of mesh-related severe complications never seems to end.

A Young Canadian Mom, Chrissy Brajcic, Loses Her Life Due to Mesh Complications

One Canadian mother of two young children has died at only 42 due to complications including heart failure and sepsis following pelvic mesh surgery to treat childbirth-induced incontinence (McCarthy, 2017).  

screen-shot-2017-12-04-at-15.30.11-0.png

Chrissy Brajcic (deceased at only 42 following mesh implant complications)

Source:  https://www.independent.co.uk/news/uk/transvaginal-vaginal-mesh-surgery-stress-urinary-incontinence-sui-uti-tvt-antiobiotic-resistance-a8092006.html

A Canadian Woman, Nonie Wideman, Changes her Mind About Committing Suicide Following Emergency Mesh Removal Surgery 

Believing to be too great a burden to their family and friends and after giving up hope altogether, some mesh victims commit suicide to end it all (McCarthy, 2017).

A woman from BC, Canada, Nonie Wideman, had emergency surgery that successfully removed the intact mesh only.  Sadly, the countless, small eroded mesh fibre pieces could not be surgically removed.

Despite intact mesh removal surgery, Nonie still suffers from chronic pelvic and low back pain including burning pain and inflammation.  This is likely due to the numerous tiny pieces of eroded mesh fibres that still remain within her pelvic area.

The good news is that Nonie is no longer contemplating suicide.  Instead, she is now an advocate for women suffering from mesh-related pain, disability and disfigurement.

In Nonie’s words,

Women are often not believed about how mesh is causing them pain or how much pain the mesh is causing them … We do … suicide watches when women start talking like they’re done, they’re finished, they can’t go on anymore’ (Akre, 2012; Favaro, 2018; Favaro & St. Philip, 2019; Welk et al, 2019).

Many Men Also Suffer Pain and Other Complications Following Botched Hernia Mesh Surgery

Over a dozen hernia patients, mainly men, in Australia suffer severe pain, agony, depression and other complications following botched hernia mesh implant surgery.

The following men share their failed hernia mesh implant stories:

 John Coady

John Coady underwent hernia-repair surgery in the mid-1990’s.  While at work in early 2010, John suffered a mesh-related complication for the first time.  Sadly, the follow-up mesh surgery was a complete disaster and immediately resulted in constant pain and other problems.  Quoting John,

‘Before the surgery I was happy, worked six days a well and was always busy … Now I am on morphine and just sit around in pain … After the surgery, my entire groin area including my penis and scrotum was black and I was in excruciating pain … It was like I’d been punched in the genitals. They were just black and just swollen beyond recognition … As the weeks turned into months, I was still suffering from immense pain and suffering.’

The surgeon was unable to alleviate the mesh-related pain and other medical issues despite John seeing the surgeon at least once a week for more than 6 months.

In John’s words,

‘… after about six months, the surgeon told me that there was nothing wrong with me … [adding] ‘I’ve done my job’ and to go away.

Dominic’s ‘Five Years of Hell’ Following Failed Hernia Mesh Surgery 

Following a botched hernia-mesh operation in 2013, Dominic (46) was left with (quoting) ‘nothing but problems with my bladder’ including pain, incontinence and urine odour.  Consequently, his social life including intimacy was virtually non-existent.

George

George, another hernia mesh victim, stated that 2 years after mesh surgery, ‘the mesh got tangled with [his] bowel.  He added:

‘I was vomiting this black stuff and I had a tube down my throat. I was in hospital for a week … surgeon … remove[d] all the mesh that was in my stomach.  Since then, hernias kept popping out …’  

Phil

Phil suffered ongoing pain in his right leg since undergoing mesh implant surgery to repair hernia years ago.  

Successful Mesh-Free Surgery for Bob Wolf, Hernia Patient

While most failed mesh implants affect women, some men also suffer following hernia mesh implants.

A mesh-free hernia surgery that was developed by an American surgeon, Dr Mohan Desarda, is now performed by many clinicians.

One satisfied American patient, Bob Wolf, underwent mesh-free hernia surgery 3 years ago in Las Vegas.  He decided to have no-mesh hernia repair after his friends told him about their pain and suffering following hernia mesh implant.

In his words,

‘I am 76, running full speed, every day at work and play’

(Wakatama, 2018).

WHAT OPTIONS EXIST, POST-MESH IMPLANT?

If chronic pelvic pain persists, surgical removal of the implanted mesh may be the only effective treatment option for some patients (see aforementioned American, French and Dutch studies).  Unfortunately, it may not always be possible to remove all of the mesh without also damaging nearby organs and tissues.  In other words, there may be residual mesh that is simply too risky to remove.

OPTIONS TO CONSIDER OTHER THAN MESH IMPLANT SURGERY

Options to try before even thinking about the unthinkable vaginal mesh implant surgery include:

Non Invasive Options 

  • Pelvic floor exercises, also known as Kegel exercises (named after Arnold Kegel, a US gynaecologist).  Kegel exercise can be taught and supervised by a physiotherapist or continence adviser, and done daily at home (Ward, 2018);
  • Yoga and pilates that aim to strengthen the pelvic regions.
  • Incontinence pads (many women opt for this non-invasive option);
  • Substitute action sports (e.g. soccer, tennis) for gentler physical activities that may lead to less ‘leakage’ … and don’t stress if there is residual ‘leakage’.  After all, that is what incontinence pads and showers are for; and
  • Maintain a healthy diet, lose weight, stop smoking and ensure good quality of sleep.  This is important for optimum autonomic nervous system function including high vagal output throughout the body including in the pelvic region.
  • Continence pessaries – these are temporarily placed inside the vagina to help prevent leakage during exercise; and
  • If concerned, see your family doctor.

Surgery Without Mesh Implant

  • Surgery that does not involve mesh implants, in particular, synthetic mesh implants (Bang & Belal, 2016).

In conclusion, please avoid vaginal mesh implants altogether.  The risk is too high that severe pelvic pain and other serious injuries may result, post-mesh implant.

IS SURGERY TO REMOVE BOTCHED MESH IMPLANTS A VIABLE OPTION FOR SOME PATIENTS?

Like all surgeries, removal of failed mesh implants has inherent risks.  As such, some mesh victims may prefer not to consider excision surgery.

Mesh removal surgery may not be in the best interest of mesh victims where the risk of injury is high.

Having said that, mesh victims are encouraged to seek medical advice from urogynaecologists and other medical professionals who specialise in mesh excisions.

A Urogynaecologist in the UK Talks About Vaginal Mesh  

A urogynaecologist in the UK named Dr Sohier (Suzy) Elneil, has performed over 250 tension-free vaginal tape (TVT) removal surgeries since 2004. This plastic implant is often used for incontinence.

When Dr Elneil met her first mesh patient with severe pelvic pain in 2004, the mesh implant (TVT) had already disintegrated.  Following complex surgery to remove the degraded mesh, the patient was finally pain free and able to return to a normal life.

Dr Elneil described another patient, a lawyer who suffered severe pain since undergoing a mesh implant 6 weeks earlier.  By the time Dr Elneil saw her, the lawyer was no longer able to work.  Alarmingly, she was also suicidal.

Quoting Dr Elneil,

‘As I was operating on her, I could see the tape was embedded into the tissues and there was ulceration in places — doing the surgery was not nice.  I kept thinking: ‘How did it get this bad in six weeks?’. Cases like this keep me going — why in this day and age women should be suffering so makes me very angry.’

Dr Elneil describes mesh removal surgery as,

‘…really hard surgery because the mesh gets embedded in the muscles and everywhere.  Even though we scan our patients, you never know what you will find until you open the lady up — and sometimes it can be quite upsetting.  To be honest, on occasions I feel bereft because I feel so emotional about it; you realise how much this woman must have been suffering.’

In reply to the journalist’s question about when she’d last had a proper holiday, Dr Elneil replied,

‘But if I go on a long break, it means more women might be left waiting in pain, and I can’t have that’ (Brown, 2018; Elkins, 2018).

There are a number of compassionate urogynaecologists, mesh removal surgeons and other medical professionals who specialise in mesh excision.  Please see your doctor if you need a referral.

Disclaimer: The story above is not an endorsement of, or a recommendation for, Dr Sohier (Suzy) Elneil (nor any other doctor or medical specialist, for that matter).  It is merely a story, and hence, it should be read as such only.  (References are provided.)  Patients should see their doctors for referrals to specialists, if they wish to do so.

SUMMARY

An Australian Senator, Derryn Hinch, stated that ‘Transvaginal mesh is one of Australia’s  greatest medical scandals’ (Marwick, 2017).  

Others call it ‘the new thalidomide’.

Legal class action suits all around the world including more than 100,000 American women clearly demonstrate the unacceptable risks of vaginal mesh implants, with legal bills expected to exceed $20 billion.

As a consequence, vaginal mesh is no longer used in Australia, Ireland and Scotland (Berger, 2019).

To protect all women, mesh implant operations should be banned altogether (McCarthy, 2017).

The risks of mesh surgery including disabling pelvic pain, compromised or non-existent sex life, loss of enjoyment of life, suicide and death certainly outweigh any purported benefits.

Finally, women adversely affected by pelvic pain caused by mesh implants should be considered for mesh reversal surgery.  This assumes, of course, that mesh excision surgery is chosen in the first place (given that any surgery has its risks). This also assumes that mesh removal surgery is in the patients’ best interests.

I hope that this blog post (that also mentions 3 mesh removal studies, being American, French and Dutch studies) may offer light at the end of a very long dark tunnel (for some).

Also, remember that you are NOT alone! As a global community, we are ALL in this together!

Reach out for support.

Finally, help spread the word that this mesh mess is no longer acceptable.

Sabina Walker

Blogger, Pain Matters (in WordPress)

PS If you believe that this information may help someone, please share this blog post via Facebook, etc.

And please tell this person to never, ever give up!

KEY

* If I find additional mesh removal studies, I will add another blog post to highlight these studies.  If you are interested in my updates, just ‘Follow’ this blog and/or my Twitter.

REFERENCES

Hope for Mesh Patients

Medical Papers and Articles – Corrective Surgery to (Partly or Fully) Reverse Failed Vaginal Mesh Implants

An American Mesh Removal Study

(1) Hou et al. Outcome of transvaginal mesh and tape removed for pain only.  (Sept 2014); 192(3): 856-60.

doi: 10.1016/j.juro.2014.04.006.

https://www.ncbi.nlm.nih.gov/pubmed/24735934

A French Mesh Removal Study

(2) Marcus-Braun, N and von Theobald, P. Mesh removal following transvaginal mesh placement: a case series of 104 operations. Int Urogynecol J. (April 2010); 21(4): 423-30.

doi:10.1007/s00192-009-1050-3.

https://www.ncbi.nlm.nih.gov/pubmed/19936589

A Dutch Mesh Excision Study

(3) Tijdink et al. Surgical management of mesh-related complications after prior pelvic floor reconstructive surgery with mesh. Int Urogynecol J. (Nov 2011); 22(11): 1395-404.

doi:10.1007/s00192-011-1476-2.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3187855/

Other Papers

(4) Bang SL, Belal M. AUTOLOGOUS pubovaginal SLINGS: back to the future or a lost art?. Res Rep Urol. 2016;8:11–20. Published 2016 Jan 18. doi:10.2147/RRU.S96957

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4723033/

(5A) Stetson, Diana. Vaginal Mesh Excision. Department of Obstetrics and Gynecology, von Voigtlander Women’s Hospital, Michigan Medicine (May 2018).

http://www.med.umich.edu/1libr/Gyn/ExcisionOfMesh.pdf

(5B) Transvaginal Mesh Removal. Colorado Women’s Health, University of Colorado Hospital.

https://urogyn.coloradowomenshealth.com/patients/library/transvaginal-mesh-removal

A UK-Based Patient, Kath Sansom, Has Mesh Removal Surgery   

(6A) Brown, Julia. ‘The pain was instant’: The devastating impact of vaginal mesh surgery. NewScientist (5 Sept 2018).

https://www.newscientist.com/article/2178297-the-pain-was-instant-the-devastating-impact-of-vaginal-mesh-surgery/

(6B) Sansom, Kath. Journalist Kath Sansom was ‘wreck’ after vaginal mesh implant. Sky News (30 Jan 2018).

https://news.sky.com/story/journalist-kath-sansom-was-wreck-after-vaginal-mesh-implant-11086123

(6C) Sansom, Kath. Vaginal mesh left me in agony. When will women’s health be taken seriously? The Guardian (27 April 2017).

https://www.theguardian.com/commentisfree/2017/apr/27/vaginal-mesh-women-health-bladders-bowels-sex-lives-nhs-operations

(6D) Briggs, Caroline. Life after vaginal mesh surgery. BBC (5 April 2019).

https://www.bbc.com/news/in-pictures-47777782

A NZ-Based Patient Undergoes Several Excision Surgeries to Remove All Mesh 

(7) Catie’s Story:

Real Kiwis, Real Stories. New Zealand – Mesh Down Under 

http://meshdownunder.co.nz/kiwi-stories

Media – Failed Vaginal Mesh Implant Stories  

Alison Blake (Suicided Following Botched Mesh Implant) 

(1) McCarthy, Joanne.’There was a look in her eyes’: Mother’s emotional torment at surgery nightmare. Sydney Morning Herald (20 December 2017).

http://www.smh.com.au/nsw/there-was-a-look-in-her-eyes-mothers-emotional-torment-at-surgery-nightmare-20171220-h080e0.html

Chrissy Brajcic (Deceased At Only 42 Following Failed Mesh Implant) 

(2A) McCarthy, Joanne. Canadian woman Christina Lynn Brajcic dies after receiving pelvic mesh implant. Sydney Morning Herald (4 December 2017).

http://www.smh.com.au/national/health/canadian-woman-christina-lynn-brajcic-dies-after-receiving-pelvic-mesh-implant-20171203-gzxsl1.html

Please watch 2-minute video of Chrissy’s sad surgical mesh story (now deceased at only 42 following mesh-related complications).

(2B) Marsden, Harriet. Vaginal mesh campaigner ‘dies of sepsis after antibiotic-resistant infection’. Independent (4 December 2017).

https://www.independent.co.uk/news/uk/transvaginal-vaginal-mesh-surgery-stress-urinary-incontinence-sui-uti-tvt-antiobiotic-resistance-a8092006.html

Jan Wise, A Mesh Implant Pain Sufferer  

(3A) McCarthy, Joanne. Pelvic mesh victim speaks out about ‘one of the greatest medical scandals in Australian history’. The Herald (23 March 2017).

http://www.theherald.com.au/story/4547363/its-so-awful-and-so-private-photos-video/?cs=5507

Please watch 3-minute video of Jan’s tragic surgical mesh story.

(3B) McCarthy, Joanne. Pelvic mesh victim speaks out about ‘one of the greatest medical scandals in Australian history’. The Herald (23 March 2017).

https://www.theherald.com.au/story/4547363/its-so-awful-and-so-private-photos-video/

The Angel’ in the UK Named Dr Sohier (Suzy) Elneil, Urogynaecologist

(4A) Brown, Julia. The inside story of the vaginal mesh scandal, from top removal surgeon. NewScientist(5 Sept 2018).

https://www.newscientist.com/article/mg23931940-300-the-inside-story-of-the-vaginal-mesh-scandal-from-top-removal-surgeon/

(4B) Elkins, Lucy. NHS Health Heroes campaign: Surgeon who works day and night to help women told they imagined their pain. Daily Mail Australia (10 July 2018).

https://www.dailymail.co.uk/health/article-5935393/Surgeon-works-day-night-help-women-told-imagined-pain.html

Other Articles and Stories from Media

(5A) Marsden, Harriet. The biggest NHS scandal you’ve never heard of only affects women, but men should be just as concerned. Independent (5 August 2017).

https://www.independent.co.uk/voices/trans-vaginal-mesh-scandal-thalidomide-tvt-gynaecology-vaginal-procedure-womens-health-feminism-a7878136.html

(5B) Marsden, Harriet. Panorama investigation reveals medical company failed to fully inform doctors of vaginal mesh risks. Independent (11 December 2017).

https://www.independent.co.uk/news/uk/home-news/vaginal-mesh-scandal-tvt-transvaginal-sling-implant-risks-thalidomide-device-bbc-panorama-a8102726.html

(6) Moss, Rachel. What is A vaginal mesh implant? Government to launch audit into complications. Huffington Post (30/1/2018).

https://www.huffingtonpost.co.uk/entry/what-is-vaginal-mesh-incontinence-treatment-risks_uk_58f71cdde4b05b9d613e6bda

(7) McCarthy, Joanne. Pelvic mesh left a man ‘stabbed’ during sex, regulator warned. The Herald (17 March 2017).

http://www.theherald.com.au/story/4535453/mesh-in-stabbing-incident/?cs=5507

(8) McCarthy, Joanne. Australian pelvic mesh victims launch their case against Johnson & Johnson. The Herald (4 July 2017).

http://www.theherald.com.au/story/4769450/pelvic-mesh-victims-in-landmark-action/?cs=2452

(9) Moodie, Claire. Vaginal mesh implants: Gynaecologist urges proactive response to health concerns. ABC News (4 July 2017).

http://www.abc.net.au/news/2017-07-04/vaginal-mesh-implants-surgeon-urges-proactive-response/8677488

(10) McCarthy, Joanne. Johnson & Johnson pelvic mesh doctor said he would not want his wife to undergo procedure, Federal Court told. Sydney Morning Herald (5 July 2017).

http://www.smh.com.au/national/johnson–johnson-pelvic-mesh-doctor-said-he-would-not-want-his-wife-to-undergo-procedure-federal-court-told-20170704-gx4i27.html

(11) Pelvic implant lawsuit underway in Sydney. 9 News (4 July 2017).

http://www.9news.com.au/national/2017/07/04/08/57/vaginal-mesh-lawsuit-to-commence

(12) Smith, Leesa. ‘Vaginal mesh implant has destroyed my life — it’s just so hard to go on’. News (11 May 2017).

http://www.news.com.au/lifestyle/parenting/kids/vaginal-mesh-implant-has-destroyed-my-life-its-just-so-hard-to-go-on/news-story/c9a78c04bbbaf0c32689ab2d0108658d

(13) For Donna’s, Catie’s, Helen’s and other mesh victim’s stories, please see:

Real Kiwis, Real Stories. New Zealand – Mesh Down Under 

http://meshdownunder.co.nz/kiwi-stories

Please note:  Catie’s story involving complete mesh removal may offer hope to other mesh patients.

(14A) Favaro, Avis. Woman appeals to Ottawa for temporary ban on female pelvic mesh. CTV News (8 January 2018).

https://www.ctvnews.ca/health/woman-appeals-to-ottawa-for-temporary-ban-on-female-pelvic-mesh-1.3750700

(14B) Favaro, Avis & St. Philip, Elizabeth. Women with pelvic mesh complications at higher risk of depression, suicidal thoughts. CTV News (9 January 2019).

https://www.ctvnews.ca/mobile/health/women-with-pelvic-mesh-complications-at-higher-risk-of-depression-suicidal-thoughts-1.4247100?fbclid=IwAR1bURcBZFWloMKbjLIacwNEeVfjeeMSaIUcBHlTAZ1S1wvEHXsNvo1WYRU

(14C) Akre, Jane. Wideman – Canadian Child Advocate and Rancher. Mesh News Desk (21/5/2012).

https://www.meshmedicaldevicenewsdesk.com/suffering-in-silence-nonie-wideman-canadian-child-advocate-and-rancher-sidelined-by-transvaginal-mesh/

(14D) Welk et al. Association of Transvaginal Mesh Complications With the Risk of New-Onset Depression or Self-harm in Women With a Midurethral Sling. JAMA Surg (9 January 2019).

doi:10.1001/jamasurg.2018.4644

https://jamanetwork.com/journals/jamasurgery/article-abstract/2719817

(15) Wakatama, Giselle. Concern grows over hernia mesh as more patients share post-surgery horror stories. ABC News (14 Sep 2018).

https://www.abc.net.au/news/2018-09-14/hernia-mesh-patients-speak-out-about-horrendous-outcomes/10242004

(16) Marwick, Jane. Why aren’t we talking more about one of Australia’s greatest medical scandals? The Daily Telegraph (29 August 2017).

https://www.dailytelegraph.com.au/rendezview/why-arent-we-talking-more-about-one-of-australias-greatest-medical-scandals/news-story/92f4cb833ba105f6e86eefd82404afe1

(17) Hooton, Amanda, & McCarthy, Joanne. The ‘eight-minute’ cure: how transvaginal mesh sentenced thousands of women to a life of pain. SMH (15 June 2019).

https://www.smh.com.au/lifestyle/health-and-wellness/the-eight-minute-cure-how-transvaginal-mesh-sentenced-thousands-of-women-to-a-life-of-pain-20190611-p51whn.html

(18) Hennessy, Michelle. Vaginal mesh implants: Women complain of delay in aftercare for severe complications. The Journal (16/6/19).

https://www.thejournal.ie/vaginal-mesh-aftercare-4682615-Jun2019/?utm_source=shortlink

Pelvic Mesh Support Groups

(1) Sling the Mesh – Raising awareness of the life changing risks of a “simple” day case operation

https://slingthemesh.wordpress.com

https://slingthemesh.wordpress.com/media-news-updates/

@MeshCampaign

(2) Australia – Mesh Down Under 

https://www.facebook.com/MeshDownUnder/

(3) New Zealand – Mesh Down Under 

http://meshdownunder.co.nz

(4) Patient Groups: Pelvic Mesh. The Independent Medicines and Medical Devices Safety Review (Dec 2018); Pages 1 – 317.

http://www.immdsreview.org.uk/downloads/Evidence/FOR%20PUBLICATION%20Patient%20Groups%20-%20Pelvic%20Mesh.pdf

Kegel Exercises For Weak Pelvic Floor Muscles

(1) Ward, Mary. A weak pelvic floor can mean more than a little leakage. Sydney Morning  Herald (18 June 2018).

https://www.google.com.au/amp/s/amp.smh.com.au/lifestyle/health-and-wellness/a-weak-pelvic-floor-can-mean-more-than-a-little-leakage-20180605-p4zjje.html

In German

(1) Wenn die Vagina plötzlich zubeißt [translated: When The Vagina Suddenly Bites]. Stern (21 March 2017).

http://www.stern.de/familie/beziehung/stressinkontinenz–wenn-die-vagina-ploetzlich-zubeisst–7377994.html

 

 

 

 

 

 

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The Colour of Pain

Feature Image sourced from:

https://www.pinterest.com.au/pin/440367669785694940/?lp=true

Dear Pain Matters blog readers,

Here is some exciting news:

Neuroscientist Professor Mark Hutchinson at The University of Adelaide in Australia recently revealed that a novel blood test can diagnose chronic pain within minutes.

CNBP-Director-Prof-Mark-Hutchinson_lab.jpg

Professor Mark Hutchinson, The University of Adelaide

http://cnbp.org.au/our-research

Called the ‘painHS’ test and available in 18 months, this novel blood test relies on hyperspectral imaging analysis (light measurement tools) to identify certain molecular structures and colour ‘biomarkers’ associated with ongoing pain.  Mark and his team observed that immune cells give off a different natural colour in the presence of chronic pain, compared to in its absence.

chronic-pain-blood-test-1.jpg

Credit: Haridy, 2018

https://newatlas.com/blood-test-chronic-pain/54507/

Patients suffering from persistent pain and unable to communicate their level of pain (e.g. babies, dementia patients and severely disabled patients) may be amongst those who will benefit from this blood test.

Quoting Mark,

‘This gives us a brand new window into patients’ pain because we have created a new tool that not only allows for greater certainty of diagnosis but also can guide better drug treatment options.’

‘We are literally quantifying the colour of pain.’

Whilst this blood test will never replace valuable information obtained from pain questionnaires, self-resports and patient discussions, it will likely be a useful adjunct for pain diagnosis and treatment (ANZCA, 2018).

What an exciting development!!

Sabina Walker

Blogger, Pain Matters (in WordPress)

REFERENCES

(1) Breakthrough Blood Test Reveals Colour of Chronic Pain. ANZCA (6 May 2018).

http://www.anzca.edu.au/breakthrough-blood-test-reveals-colour-of-chronic

(2) Haridy, Rich. Revolutionary New Blood Test Can Instantly Identify Chronic Pain. New Atlas (7 May 2018).

https://newatlas.com/blood-test-chronic-pain/54507/

(3) Snook, Julie. Breakthrough blood test reveals chronic pain in colour. 9news (6 May 2018).

(Includes a 2-minute video)

http://www.adelaidenow.com.au/news/national/breakthrough-blood-test-reveals-chronic-pain-in-colour-9news/video/679b3f3bb53699b21d8dffd3bef70a98

(4) Curing chronic pain – University of Adelaide researchers unravel mysteries of the pain puzzle. Adelaidean – The University of Adelaide (2019).

https://www.adelaide.edu.au/adelaidean/issues/60481/news60561.html

 

 

‘Poking Long Pointy Needles’ – Needling Including Ultrasound-Guided Needling of Myofascial Trigger Points for Pain Relief

Feature Image Credit: Studio Musculoskeletal

https://studioms.com.au/pages/dry-needling

Dear Pain Matters blog readers,

Recently, I had the honour and pleasure of meeting one of Vancouver’s most respected pain clinicians, Dr Gillian Lauder, pediatric anesthesiologist, complex pediatric pain physician and director of the Acute Pain Service in the Department of Pediatric Anesthesia at BC Children’s Hospital.

I first heard about Dr Lauder’s work after reading an inspirational story about a young girl named Anaïs Poirier whom Dr Lauder had successfully treated for CRPS.  After a full recovery from CRPS, and in response to a question about who her hero was, Anaïs replied:

‘That’s an easy one! Dr. Lauder, because she saved my life. I know pain doesn’t kill you, but it takes everything away from you.’

Giving a Voice to Children who Suffer from Chronic Pain

https://www.theglobeandmail.com/life/giving/giving-a-voice-to-children-who-suffer-from-chronic-pain/article4400974/

Dr Lauder has also published a book called Complex Regional Pain Syndrome (CRPS) Explained – For Teenagers, By Teenagers (available in Amazon).

Over coffee, Dr Lauder and I discussed various topics including needling of myofascial trigger points for pain relief.

Inspired by Gillian’s comments, today’s blog post is dedicated to needling of myofascial trigger points – with or without medication or saline only injections – for pain relief.

INTRODUCTION

Overview

The objective of needling of myofascial trigger points is pain relief as well as enhanced movement and mobility.

Needling techniques vary and may include:

  • Dry needling (aka non-injection needling);
  • Pharmaceutical injection needling including lidocaine and corticosteroid injection needling; and
  • Saline only-injection needling (see future blog post on myoActivation, developed by Dr Greg Siren).

Trigger points are identifiable via:

(1) Clinical examination including manual palpation – to feel densified tissue regions;

(2) Ultrasound imaging – to locate hypoechogenic areas in muscle (more later); and

(3) Thermal analysis (more later) (Cojocaru et al, 2015).

A study by Stecco et al (2013) suggested that excess hyaluronic acid may be a contributing factor for trigger points.

Presumably, needling of trigger points (that also leads to the ‘local twitch response’) results in release of excess hyaluronic acid as well as reduced pressure and inflammation in the immediate surrounding area.

Some definitions:

Dry needling (aka non-injection needling or nonacupoint needling) means that needles without saline or medical injections (e.g. without lidocaine and other anaesthetics, corticosteroids or botox) are used to target myofascial trigger points.

Myofascial active trigger points are sore, hypersensitive/hyperirritable, palpable hard nodules (‘tender points’, or ‘knots’) located within the myofascia that surrounds a taut band of skeletal muscle.  Compression of these trigger points may result in pain as well as motor and autonomic dysfunction.  Local pressure or stretch of tissue may also activate trigger points.

Referred pain is pain that may radiate from trigger points into larger areas that may even be remote to trigger points.

What exactly is dry needling of myofascial trigger points?:

Insertion of needles into palpable nodules (ie rapid, brief mechanical stimulation of active trigger points) in the myofascia results in an involuntary spinal reflex.  Specifically, trigger point needling elicits a sudden involuntary muscle contraction (local twitch response) in the taut band.

Local twitch responses in superficial trigger points can easily be seen while twitch responses occurring more deeply may only be visible via real-time ultrasonography.

Once a local twitch response is elicited, deactivation of the trigger point occurs and myofascial tension relief, reduced pain and improved musculoskeletal function result.  

Twitch responses may also be achieved during non invasive treatments including transcutaneous electrical stimulation, manual compression of trigger points and massage.

NB Twitch responses are not the same as muscle spasms.  Whilst the entire muscle is involved in both cases, the twitch response refers to a small spontaneous twitch only, and not an entire muscle contraction (as in muscle spasms).    

CASE STUDIES

(1) Ultrasound-Guided Trigger Point Needling for Myofascial Pain  

A Ukrainian study involving 133 myofascial pain patients compared ultrasound-guided versus non-ultrasound-guided trigger point needling.  Average pain levels were 7.2 and 7.4, respectively, prior to dry needling treatment.

Ultrasound scanning was done to precisely identify myofascial trigger points.

Dry needling was performed over 2 – 4 session to inactivate all trigger points.  Steel acupuncture needles (28 gauge) were used during dry needling treatments.

This study found that ultrasound-guided trigger point needling led to enhanced pain relief by evoking a greater number of local twitch responses.  Specifically, pain levels dropped from an average of 7.2 to 1.1 within 24 hours following ultrasound-guided trigger point needling.  This compares to average pain level decreases from 7.4 to 2.7 in the non-ultrasound-guided dry needling group (Bubnov and Wang, 2013).

(2) Ultrasound-Guided Trigger Point Needling (Including Medication Injection) in Patients with Chronic Chest Wall Pain Following Surgery    

Eight patients (7 women and 1 man; mean age = 56; 47 to 74) suffered severe chest wall pain (serratus anterior muscle pain syndrome) for 1 to 3 years, with pain levels ranging from 7 to 10.  The chest wall pain had started after surgery for lung cancer (n=2), cardiac surgery (n=2) and total mastectomy (n=4).

Once the trigger points in the serratus anterior muscle were identified, all 8 patients were offered 1 – 3 injections over 3 months.

Ultrasound-guided injection of medicine into the infiltration sites was performed to deactivate the trigger points.  Medication comprised lidocaine, bupivacaine and triamcinolone.

Ultrasound-guided trigger point injection treatment resulted in reduced pain levels (down to 3 or 4) in all 8 patients shortly after the first injection as well as 55% less pain (on average) after 3 months.   

(3) A 29 Year Old Female with Myofascial Pain Syndrome

A 29 year old female patient (let’s call her ‘Annie’) suffered myofascial pain syndrome in her left orofacial region for 3 months (pain rating up to 9).  Annie’s pain was dull, diffuse and ongoing.  Her pain affected her left ear and pre-auricular region, extended to her left temporal area and was accompanied by a headache.  Annie’s pain increased while chewing food and she was unable to open her mouth widely.  Her quality of sleep was also affected.

Following palpation, myofascial trigger points over her masticatory and suboccipital muscles were identified as well as referred pain to her left ear and a taut muscle band.  

Annie was offered 3 deep dry needling sessions over a week to deactivate the myofascial trigger points in the orofacial muscles.  

During Annie’s 1st appointment, the exact locations of her myofascial trigger points were identified via palpation of the affected muscles.  Thereafter, dry needling of her sternocleidomastoid and masseter using a 25 mm stainless steel needle was done.  The needle was positioned perpendicular to the trigger points before performing the ‘lift and thrust’ maneuver to evoke the local twitch response.  

During her 2nd appointment, Annie stated that half of her pain was gone and that her headache was now significantly reduced!  She was also able to open her mouth wider.  Dry needling of her lateral pterygoid (via a 40 mm needle), temporalis (via a 13 mm needle) and deep masseter muscles was performed resulting in a local twitch response in the masseter.

On her 3rd visit (on the 7th day), Annie finally had NIL pain!  There was no pain following palpation of the sternocleidomastoid, masseter, digastric and suboccipital muscles and her myofascial trigger points were no longer tender.  Her headache had disappeared shortly after her 2nd session and she was now able to open her mouth widely. 

Complete resolution of Annie’s myofascial pain syndrome via needling demonstrates the benefits of dry needling in patients with non-dental orofacial pain (Asha et al, 2015).

(4) A 40 Year Old Male with Myofascial Pain Syndrome

A 40 year old man suffered posterior thigh pain despite massage therapy, chiropractic adjustments and physical therapy.  Myofascial pain syndrome in the quadratus femoris was diagnosed following palpation.  Dry needling (based on a grading system) was offered.

The patient enjoyed immediate benefits following dry needling treatment.  Furthermore, he was completely pain free at the 4-month follow-up consultation (Anandkumar, 2017).

(5) An Iranian Clinical Trial Involving Dry Needling of Myofascial Trigger Points for Heel Pain  

A single-blinded clinical trial involving 20 patients with chronic heel pain due to plantar fasciitis revealed that a weekly session of dry needling of myofascial trigger points for 4 consecutive weeks can reduce the severity of heel pain (Eftekharsadat et al, 2016).

(6) A 53 Year Old Male with Painful Plantar Fasciitis

A 53 year old Iranian man suffered bilateral plantar heel pain that involved sharp, stabbing pain and accumulation of fluid beneath the metatarsal heads.  Pain levels were 8 in the right foot and 6 in the left foot and he was unable to stand for more than 20 minutes at a time.  

Dry needling of myofascial trigger points was offered twice a week for 2 weeks.

The man enjoyed a 60-70% decrease in pain levels (ie his pain levels dropped from 8 to 3 in his right foot and from 6 to 2 in his left foot), and he was able to return to his normal daily activities.   

THE SCIENCE BEHIND NEEDLING OF MYOFASCIAL TRIGGER POINTS FOR PAIN RELIEF 

What do trigger points look like?

Ultrasound images of trigger points from 3 studies are shown below:

(1) An Indian ultrasound study found that trigger points appear as echogenic structures under the surface of the trapezius muscle (and not inside the muscle mass).  These echogenic structures do not appear in or around unaffected, healthy skeletal muscle.

Here is an example of an echogenic structure (i.e. trigger point):

Credit for above ultrasound image of a trigger point: Parthasarathy et al, 2017.

 

(2) An American paper called Dry Needling for Myofascial Trigger Point Pain included 2 ultrasound images (A and B, below).  In A, a trigger point appears as a focal hypoechoic nodule in the upper trapezius.  In B, four (4) hypoechoic myofascia trigger points are visible.

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Credit for above ultrasound images: Unverzagt et al, 2015.

 

(3) A Romanian ultrasound- and thermal-based study identified trigger points via:

  • Clinical examination;
  • Ultrasound imaging; and
  • Thermal analysis.  

Thermal analysis via infrared thermography revealed that trigger points have higher temperatures than the areas immediately surrounding them.  It is possible that reduced blood flows lead to decreased temperatures around trigger points.

Thus, trigger points have unique thermal patterns.  Specifically, a cooler region surrounds a hotter area, the latter representing the trigger points themselves.  NB The thermal images are available in the paper by Cojocaru et al, 2015.

The trigger points could no longer be detected during follow-up clinical and ultrasound examination done 5 days after the successful injection procedure.

A trigger point, described as (quoting from paper) ‘an ellipsoidal hypoechogenic area in the muscle’, is seen here:

 

JMedLife-08-315-g001.jpg

Credit for above ultrasound image of a trigger point: Cojocaru et al, 2015.

 

(4) Many ultrasound images of trigger points are available in literature (Wong, 2017; Mayoral et al, 2013; other papers).

Benefits of Ultrasound Imaging of Trigger Points

Ultrasound-guided needling of trigger points can enhance the accuracy of needle placement in deeper musculature and intraarticular regions hence reducing the risk of pneumothorax, needling damage to organs and tissue (eg kidneys, lungs, salivary glands, adipose) as well as other complications (Botwin et al, 2008).    

Is dry needling of trigger points similar to acupuncture?

Researchers have suggested that the entire fascia network may be the physical substrate of all acupuncture-related meridians (the latter having been part of Traditional Chinese Medicine for 1,000’s of years).  Peter Dorsher noted an 89% overlap in myofascial meridians and the acupuncture principal meridian (Behnam et al, 2015).  Dorsher also found that 92% of all 255 trigger points correlated with acupuncture points.  The local twitch response can be compared to acupuncture’s ‘de qi’ sensation (Bai et al, 2011; Dorsher, 2006; Dorsher, 2009).

These observations suggest a positive correlation between the anatomy-based dry needling of trigger points and acupuncture.  

SUMMARY

The science behind dry needling (aka non-injection) vs injection needling of trigger points is incomplete.  Many medical professionals are still sceptical about this procedure.  Quoting from a paper offering a critical view (see Abstract):

‘…the theory of MPS [myofascial pain syndrome] caused by TrPs [trigger points] has been refuted…’ (Quintner et al, 2015).

Ongoing research that includes imaging (e.g. real-time ultrasonography) to specifically locate and identify the trigger points during dry needling (puncture) will enhance the underlying science and credibility for this technique.

Real-time ultrasound imaging can also enhance the accuracy of trigger point needling, particularly when targeting hyperactive trigger points located within the deeper fascia and musculature layers, intraarticular regions and other areas that cannot be palpated.  This reduces the risk of pneumothorax and other complications that may otherwise result from ‘blind methods’ (Mayoral et al, 2013).  

Dry needling of myofascial trigger points may offer effective and long-lasting pain relief, reduced focal inflammation, regeneration, increased mobility and enhanced autonomic function for patients suffering from musculoskeletal pain and/or myofascial pain syndromes.

Note: For patients who have a fear of needles (i.e. needle phobia), hypnotherapy may be beneficial.  For further information, please refer to my blog post called ‘Chronic Pain and Hypnotherapy’.

Sabina Walker

Blogger, Pain Matters (in WordPress)

PS A follow-up blog post on The myoActivation System of Pain Care (developed by Dr Greg Siren, BC, Canada) will be added shortly.  Stay tuned…

REFERENCES

Case Studies

(1) Ultrasound-Guided Trigger Point Needling for Myofascial Pain  

Bubnov and Wang. Clinical Comparative Study for Ultrasound-Guided Trigger-Point Needling for Myofascial Pain. Medical Acupuncture (17 Dec 2013); 25(6): 437-443.

https://www.researchgate.net/publication/259189884_Clinical_Comparative_Study_for_Ultrasound-Guided_Trigger-Point_Needling_for_Myofascial_Pain

(2) Ultrasound-Guided Trigger Point Needling (Including Medication Injection) in Patients with Chronic Chest Wall Pain Following Surgery  

Vargas-Schaffer et al. Ultrasound-Guided Trigger Point Injection for Serratus Anterior Muscle Pain Syndrome: Description of Technique and Case Series. A&A Case Reports (15 Sept 2015): 5(6); 99-102.

https://journals.lww.com/aacr/Fulltext/2015/09150/Ultrasound_Guided_Trigger_Point_Injection_for.4.aspx

(3) A 29 Year Old Female with Myofascial Pain Syndrome

Asha et al. A Novel Case of Orofacial Pain Treated by Dry Needling Technique – A Case Report. Dentistry (2015); 5: 319.

http://www.academia.edu/25006600/Open_Access_Case_Report_A_Novel_Case_of_Orofacial_Pain_Treated_by_Dry_Needling_Technique_-A_Case_Report

(4) A 40 Year Old Male with Myofascial Pain Syndrome

Anandkumar, S. Effect of Dry Needling on Myofascial Pain Syndrome of the Quadratus Femoris: A Case Report. Physiotherapy Theory and Practice (Feb 2018); 34(2): 157-164. 

https://www.ncbi.nlm.nih.gov/pubmed/28922048

(5) An Iranian Clinical Trial Involving Dry Needling of Myofascial Trigger Points for Heel Pain  

Eftekharsadat et al. Dry Needling in Patients with Chronic Heel Pain Due to Plantar Fasciitis: A Single-Blinded Randomized Clinical Trial. Medical Journal of the Islamic Republic of Iran (2016); 30: 401.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038993/

(6) A 53 Year Old Male with Painful Plantar Fasciitis

Behnam et al. The Use of Dry Needling and Myofascial Meridians in a Case of Plantar Fasciitis. J Chiropr Med. (March 2014); 13(1): 43–48.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976498/?report=reader#__ffn_sectitle

Other Academic References

(1) Mayoral et al. Myofascial Trigger Points: New Insights in Ultrasound Imaging. Techniques in Regional Anesthesia and Pain Management (July 2013); 17(3): 150–154.  

http://www.asociacionandaluzadeldolor.es/wp-content/uploads/2017/02/US-miofascial.pdf

(2) Mayo Clinic. Acupuncture And Myofascial Trigger Therapy Treat Same Pain Areas. ScienceDaily (14 May 2008).

http://www.sciencedaily.com/releases/2008/05/080513101614.htm>

(3) Dorsher PT. Trigger Points and Acupuncture Points: Anatomic and Clinical Correlations. Medical Acupuncture (May 2006); 17.

(4) Dorsher PT. Myofascial Referred-Pain Data Provide Physiologic Evidence of Acupuncture Meridians. J Pain (July 2009); 10 (7): 723–31.

doi:10.1016/j.jpain.2008.12.010

(5) Liu et al. Traditional Chinese Medicine Acupuncture and Myofascial Trigger Needling: The Same Stimulation Points? Complementary Therapies in Medicine (2016); 26: 28-32.

doi:10.1016/j.ctim.2016.02.013.

(6) Bai et al. Review of Evidence Suggesting That the Fascia Network Could Be the Anatomical Basis for Acupoints and Meridians in the Human Body (2011). Evidence-Based Complementary and Alternative Medicine (2011); Article ID 260510, 6 pages.

http://dx.doi.org/10.1155/2011/260510

https://www.hindawi.com/journals/ecam/2011/260510/

(7) Unverzagt et al. Dry Needling for Myofascial Trigger Point Pain: A Clinical Commentary. International Journal of Sports Physical Therapy. 2015;10(3):402-418.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458928/pdf/ijspt-06-402.pdf

(8) Wong YM. Developments of Nonacupoint Needling in Japan. Medical Acupuncture (2017); 29(6): 349-351.

doi:10.1089/acu.2017.1247.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733641/

(9) Botwin et al. Ultrasound-Guided Trigger Point Injections in the Cervicothoracic Musculature: A New and Unreported Technique. Pain Physician (Nov/Dec 2008); 11(6): 885-9.

https://www.ncbi.nlm.nih.gov/pubmed/19057634

(10) Parthasarathy S, John Charles S A. Analgesic Efficacy of Ultrasound Identified Trigger Point Injection in Myofascial Pain Syndrome: A Pilot Study in Indian Patients. Indian J Pain (2016); 30: 162-5.

http://www.indianjpain.org/article.asp?issn=0970-5333;year=2016;volume=30;issue=3;spage=162;epage=165;aulast=Parthasarathy

(11) Wong YM. Developments of Nonacupoint Needling in Japan. Medical Acupuncture (2017) ;29(6): 349-351.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733641/

(12) Myofascial Trigger Point

https://en.wikipedia.org/wiki/Myofascial_trigger_point

(13) Zhou K, Ma Y & Brogan MS. Dry needling versus acupuncture: the ongoing debate. 

https://aim.bmj.com/content/33/6/485

(14) Cojocaru MC, Cojocaru IM, Voiculescu VM, Cojan-Carlea NA, Dumitru VL, Berteanu Met al. Trigger points–ultrasound and thermal findings. J Med Life (2015); 8(3): 315-8.

https://www.ncbi.nlm.nih.gov/pubmed/26351532

(15) Stecco et al. Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep (2013); 17: 352.

https://spinalmanipulation.org/wp-content/uploads/2017/04/fascial-components-of-myofascial-pain-syndrome-2013.pdf

(16) Quintner, Bove and Cohen. A Critical Evaluation of the Trigger Point Phenomenon, Rheumatology (1 March 2015); 54(3): 392–399.

https://academic.oup.com/rheumatology/article/54/3/392/1796114