Researchers and expert clinicians in orofacial pain have long acknowledged the Differential DiagnosisIn addition to the musculoskeletal structures (TMJ and the masticatory muscles) and the psychological factors discussed, orofacial pain may result from or be exacerbated by (1) primary HAs (migraine, cluster, tension type, other primary); (2) secondary HAs related to systemic problems such as cardiovascular and rheumatoid disorders and disorders related to the cervical spine, ears, sinuses, eyes, medications, and dental structures; and (3) cranial and peripheral neuralgias and central nervous system disorders.The following provides an overview of the physical therapy examination for people presenting with HAs and/or orofacial pain. The examination will consist of the history, screens for contributing psychological factors, a systems screen, cervical spine screen, and specific examination of the TMJ and masticatory muscles. PHYSICAL THERAPY EXAMINATION HistoryA thorough history will help identify the possible source(s) of the orofacial pain and provide a screen for other causative or contributing factors. 17,22,61,74,75 Red flags related to cardiac history (eg, angina or history of myocardial infarction) and brain function (eg, sudden-onset severe HAs, weakness, or slurred speech) must be investigated early in the history taking. Information about the nature of the pain will be critical in determining the possibility of primary HAs (migraine, cluster) (TABLE 3) and secondary HAs related to the eyes, ears, sinus, dental structures, medication complications, and/or neurologic types of pain. Unrelenting pain unrelated to musculoskeletal function is an indication for referral. Information about cervical dysfunction is essential to determine whether the cervical spine is causing or exacerbating the HA/facial pain. Medication history is important to determine potential negative interactions, rebound HAs from overuse (as occurs with nonsteroidal anti-inflammatory drugs), or withdrawal.Key questions have been examined and determined to have strong sensitivity and specificity in incriminating TMDs as the source of pain. 22,29 The initiating question is, "Have you had pain or stiffness in the face, jaw, temple, in front of the ear, or in the ear in the past month?" A positive response should be followed with a question about whether the symptoms are altered by any of the following jaw activities: chewing, talking, singing, yawning, kissing, moving the jaw. 22,29,74,75 The other key inquiry is directed toward identifying the presence of a disc displacement 22,74 : "Have you ever had your jaw lock or catch so that it would not open all the way? If so, was this limitation in jaw opening severe enough to interfere with your ability to eat? Have you ever noticed clicking, popping, or other sounds in your joint?" 74 importance of the psychological domain in causing and/or maintaining pain, and in upregulating peripheral and central neural structures involved in nociception. 22,32,74,75 Central nervous system differences in the t...

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This quarter's overview of the myofascial pain literature includes quite a few basic research papers in addition to the usual high quantity of dry needling (DN) papers. Of particular interest are a study by Fischer and colleagues studying the role of mitochondrial functions in chronic trigger points (TrPs) (Fischer et al 2018), a study by Li and associates who conducted a quantitative proteomics analysis to identify biomarkers of chronic myofascial pain and therapeutic targets of dry needling in a rat model of TrPs (Li et al 2019), and a sonography study by Mitchell et al. looking into the distances from the skin to the pleura in the context of DN (Mitchell et al 2019). A total of 33 papers are included in this overview article.

Pre-SCS patients possibly underreport psychological symptoms perhaps to gain SCS approval for SCS. Separate norms and cutoffs for pre-SCS psychological evaluations may be needed to better identify risks of unsuccessful outcomes. Validity scales for measures of psychological distress also could be developed to detect biased reporting. Alternatively, referring clinicians may have referred patients for BPM who were more psychologically distressed and perceived as more in need of psychosocial intervention than those referred for pre-SCS evaluations. Further investigation of clinical referral decisions and assessment bias is warranted to clarify the meaning of these differences and how they apply to patient outcomes.

We are starting 2020 with 6 basic research studies, 9 review articles, 14 dry needling/injection studies, and one manual therapy paper for a total of 30 new papers. Topics range from studies on mechanisms, inflammatory mediators in myofascial pain, fascia, screening, Platelet-rich plasma intramuscular injections, and temporal summation to clinical studies on patients with tension-type headache, chronic pelvic pain, knee osteoarthritis, plantar fasciitis, generalized musculoskeletal pain, neck pain, breast cancer, tendinopathies, thoracic outlet syndrome, and canine dry needling, among others.