Objectives: Myofascial trigger point (MTrP) is a pillar pathophysiological unit in development of myofascial pain [1] and postural imbalance [2]. Dry needling (DN) of MTrP under ultrasound (US) guidance is prioritized method for treatment myofascial pain. Hypoxia-related signaling pathways play important role in development of rheumatic diseases and cancer [3,4].

Hypothesis: MTrP are spastic hypovascularized hypoxic low energy areas that can produce organismic signaling, associated with niches in Flammer syndrome [3,4].

Objectives: The aim was to evaluate structure of MTrP in regard to stiffness and “ischemic pattern” before and after DN.

Methods: We included 40 patients (26 females, aged 18–68 y.o.) with low back pain. Healthy 20 individuals (aged 18–52 y.o.) were controls. All patients underwent general exam, MRI, precise physical tests, extensive functional multiparameter neuromuscular US including M-mode, elastography (SWE), B-Flow (LOGIC E9 GE) of multifidus muscles. Then patients received DN of detected MTrP under US guidance.

Results: We successfully detected MTrP as hypoechoic, stiff and hypovascular small areas with different patterns of decreasing motility, contractility (muscle contracted/rested thickness) in all patient and did precise DN. After DN muscle structure improved, motility, contractility restored, VAS scores changed from 7.4 to 2.3 (p <0.05). SWE was 11±6 kPa in MTrP (27 kPa in active, 5-8 kPa in latent MTrP) vs 3.8±0.3 kPa in controls and decreased to 4±0.4 kPa after treatment. Hypovascularity (“ischemic pattern”) size decreased from 3-4 mm to 0-1.5 mm, correlated with muscle function. Preliminary we found MTrP with more expressed hypovascular pattern, higher sensitivity and retaining levels of in individuals lower BMI and patient with Flammer phenotype [3,4] (13-15/15 positive responses to questionnaire).

Conclusion: MTrP are stiff and most likely hypoxic areas, parameters improved after precise DN. US hunting for “ischemic pattern” markers can be important for patient stratification and targeted treatment and prevention. Metabolic profiling including HIF signaling, proteomic data collecting needed for further investigation for effective patients stratification. For the follow-up studies a correlation of the Flammer syndrome phenotype with individualised profiles of patients and diagnosed ischaemic patterns is recommended.

References: [1]Bubnov RV: Evidence-based pain management: is the concept of integrative medicine applicable? EPMA J 2012; 3(1):13.

[2]Bubnov R, Kalika L. EFFECTIVE RESTORING MOTION AND EFFECTIVE TREATMENT OF MYOFASCIAL AND NEUROPATHIC LOW BACK PAIN BY TARGETED DRY NEEDLING USING ULTRASOUND GUIDANCE. Annals of the Rheumatic Diseases 2019;78:1921-1922. http://dx.doi.org/10.1136/annrheumdis-2019-eular.5533

[3]Flammer Syndrome: From Phenotype to Associated Pathologies, Prediction, Prevention and Personalisation. Ed. by Olga Golubnitschaja. Springer International Publishing, 2019: 340.

4.Bubnov R, Polivka J, Zubor P, Konieczka K, Golubnitschaja O. “Pre-metastatic niches” in breast cancer: are they created by or prior to the tumour onset? “Flammer syndrome” relevance to address the question. EPMA J. 2017;8(2):141–57.

Disclosure of Interests: None declared