MPS in patients with CA 2022

Inspired by Hasuo et al 2021a&b and Ishiki et al 2021.[1–3]

Graphic by MC shows characteristic referred pain patterns from the most common trigger points in trapezius on the right and other possible sites of trapezius trigger points on the left.

MPS – myofascial pain syndrome
CA – cancer (in this case ‘incurable’ cancer) aka ‘the big C’
EA – electroacupuncture
MA – manual acupuncture
TPI – trigger point injection
LA – local anaesthetic
NRS – numerical rating scale
SRs – systematic reviews

key to acronyms

Still on the subject of the big C at the start of 2022, this is a series of 3 quite recently published papers that share the term ‘incurable cancer’ in the title. Unsurprisingly they all come from the same group in Osaka, Japan. Perhaps the surprise is they all appeared in my recently published folder in the last 3 months.

When I checked out one of the lead authors on PubMed (HH), I found he had published 8 papers in the past 2 years with ‘incurable cancer’ in the title.[1–8]

The papers popped up on my searches because of the mention of myofascial pain, but I am afraid to say there is no mention of EA, MA or dry needling. Instead, they choose TPI with LA as their treatment of choice. Clearly they haven’t read my first SR on the subject from 2 decades ago![9]

Alexisomia – difficulties in the awareness and expression of bodily feelings

The first paper is a secondary analysis of a cross-sectional survey on alexisomia in patients with incurable cancer at 2 university hospitals in Japan.[4] Alexisomia is characterised by difficulties in the awareness and expression of bodily feelings – not to be confused with alexithymia, which is a personality trait characterized by difficulty in expressing emotions and in identifying one’s own feelings and those expressed by others.

Patients with alexisomia were 4 times more likely to have latent TrPs

I remember noticing this paper when it came out in June 2021, but at the time it did not make it to the blog. In this original study, of the 262 patients included, those with alexisomia were 4 times more likely to have latent TrPs in upper trapezius than those without it. The secondary analysis was restricted to patients with upper back pain. Of this group (n=103), 20 had cancer-related pain, 53 had noncancer-related pain, and 28 had both. Of the noncancer-related pain, the majority (88.9%) was myofascial pain. Pain scores were significantly higher in those with noncancer-related pain, and they had suffered pain for twice as long on average. Use of opioids was highest in the group with both cancer-related and noncancer-related pain, and in those taking opioids, the dose was lowest in the group who only had noncancer-related pain.

the armchair sign

The second paper caught my attention because of the armchair sign, which I had not come across before.[2] It is also a secondary analysis of a prior observational study, which is not referenced… but it looks as though it is the third one I have selected.[3] Anyway, the armchair sign is a simple test where a patient’s arm is raised to 90 degrees and held there. The patient is asked to relax the arm and say when it is fully relaxed, and then the examiner lets go of the arm to see if it drops to the side of the patient. If it does not drop that is a positive test.

Of the 101 patients enrolled in the study, 44 had MPS and of them, 27 had psychosomatic prone MPS, that is they answered yes to the question: ‘Does your MPS pain worsen with stress?” The armchair sign had 100% specificity and positive predictive value, but only 41% sensitivity and just over 50% negative predictive value. That means it is a very useful test if positive but not so useful if negative.

The third paper examines the prevalence of MPS and the effect of TPI in patients with incurable cancer. It included 101 patients from 5 institutions in Japan who rated their pain on NRS (0-10) as greater than or equal to 4. Most had distant metastases (94) and 39 had MPS including a total of 83 different sites.

40 sites were treated with TPI and there was significant reduction in pain when rated the following day. This is unsurprising since any form of needling in or near TrPs seems to have a large effect in the short term.[9]

I was shocked to read the last line of the paper: “A confirmatory study investigating TPI efficacy is in preparation.” Particularly so since the authors failed to reference any of the SRs on the subject.[9–12] Instead they selectively referenced a narrative review,[13] and a few small trials. The key trials used to support the TPI intervention were a small open trial in an emergency department (n=62),[14] and a comparative trial from China with 5 parallel arms of different TPI interventions (n=120),[15] which should have been way underpowered but instead claimed highly significant differences between groups.


1          Hasuo H, Sakai K. Clinical Characteristics of Noncancer-Related Upper Back Pain on Initiation of Palliative Care in Patients with Incurable Cancer. Palliat Med Rep 2021;2:335–9. doi:10.1089/pmr.2021.0044

2          Hasuo H, Ishiki H, Matsuda Y, et al. The Usefulness of the Armchair Sign for the Diagnosis of Psychosomatic-Prone Myofascial Pain Syndrome in Patients with Incurable Cancer: A Secondary Analysis of a Prospective Multicenter Observational Clinical Study. Palliat Med Rep 2021;2:250–4. doi:10.1089/pmr.2021.0033

3          Ishiki H, Hasuo H, Matsuda Y, et al. Prevalence of myofascial pain syndrome and efficacy of trigger point injection in patients with incurable cancer. A multicenter, prospective observational study. (MyCar study). Pain Med Published Online First: 23 December 2021. doi:10.1093/pm/pnab350

4          Hasuo H, Sakai K. Clinical characteristics of alexisomia in patients with incurable cancer. Ann Palliat Med 2021;10:10244–52. doi:10.21037/apm-21-1503

5          Hasuo H, Matsuoka H, Matsuda Y, et al. The Immediate Effect of Trigger Point Injection With Local Anesthetic Affects the Subsequent Course of Pain in Myofascial Pain Syndrome in Patients With Incurable Cancer by Setting Expectations as a Mediator. Front Psychiatry 2021;12. doi:10.3389/fpsyt.2021.592776

6          Hasuo H, Ishikawa H, Matsuoka H. Relationship between the number of breaths that maximizes heart rate variability and height in patients with incurable cancers. Complement Ther Med 2021;63:102780. doi:10.1016/j.ctim.2021.102780

7          Fujii R, Hasuo H, Sakuma H, et al. The efficacy and safety of intravenous chlorpromazine treatment for sleep disturbance in patients with incurable cancer, with oral administration difficulty: a 1-week, prospective observational study. Ann Palliat Med 2021;10:8547–56. doi:10.21037/apm-21-948

8          Hasuo H, Kanbara K, Shizuma H, et al. Short-term efficacy of home-based heart rate variability biofeedback on sleep disturbance in patients with incurable cancer: a randomised open-label study. BMJ Support Palliat Care Published Online First: 21 September 2020. doi:10.1136/bmjspcare-2020-002324

9          Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: A systematic review. Arch Phys Med Rehabil 2001;82:986–92. doi:10.1053/apmr.2001.24023

10        Scott NA, Guo B, Barton PM, et al. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. Pain Med 2009;10:54–69. doi:10.1111/j.1526-4637.2008.00526.x

11        Sousa Filho LF, Barbosa Santos MM, Dos Santos GHF, et al. Corticosteroid injection or dry needling for musculoskeletal pain and disability? A systematic review and GRADE evidence synthesis. Chiropr Man Ther 2021;29:49. doi:10.1186/s12998-021-00408-y

12        Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF, et al. Dry Needling versus Trigger Point Injection for Neck Pain Symptoms Associated with Myofascial Trigger Points: A Systematic Review and Meta-analysis. Pain Med 2021;:pnab188. doi:10.1093/pm/pnab188

13        Galasso A, Urits I, An D, et al. A Comprehensive Review of the Treatment and Management of Myofascial Pain Syndrome. Curr Pain Headache Rep 2020;24:43. doi:10.1007/s11916-020-00877-5

14        Yanuck J, Saadat S, Lee JB, et al. Pragmatic Randomized Controlled Pilot Trial on Trigger Point Injections With 1% Lidocaine Versus Conventional Approaches for Myofascial Pain in the Emergency Department. J Emerg Med 2020;59:364–70. doi:10.1016/j.jemermed.2020.06.015

15        Xie P, Qin B, Yang F, et al. Lidocaine Injection in the Intramuscular Innervation Zone Can Effectively Treat Chronic Neck Pain Caused by MTrPs in the Trapezius Muscle. Pain Physician 2015;18:E815-826.

Declaration of interests MC