The majority of high-quality studies included in this review show measured benefit from TDN for MTrPs in multiple body areas, suggesting broad applicability of TDN treatment for multiple muscle groups. Further high-quality research is warranted to standardise TDN methods to determine clinical applicability.

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to implement medication-assisted treatment (MAT) in primary care settings.Methods: A 12-session weekly curriculum was delivered to participating primary care providers and clinic staff (N=24 participants from 13 clinics). Participants completed attendance logs and a qualitative interview in order to identify factors that influence engagement in the ECHO sessions and the potential integration of MAT.Results: Primary care providers and staff valued the ECHO sessions, but overall attendance was low and variable. Participants generally valued the didactic and interactive nature of the sessions but identified system-level constraints that limited engagement. Major barriers to participation included competing demands in patient care and the low degree of endorsement by clinic leadership.Conclusions: This brief report identifies key systematic challenges that may directly limit primary care providers' engagement in telementoring models such as Project ECHO.

BackgroundOpioid overdose deaths occur in civilian and military populations and are the leading cause of accidental death in the USA.ObjectiveTo determine whether ECHO Pain telementoring regarding best practices in pain management and safe opioid prescribing yielded significant declines in opioid prescribing.DesignA 4-year observational cohort study at military medical treatment facilities worldwide.ParticipantsPatients included 54.6% females and 46.4% males whose primary care clinicians (PCCs) opted to participate in ECHO Pain; the comparison group included 39.9% females and 60.1% males whose PCCs opted not to participate in ECHO Pain.InterventionPCCs attended 2-h weekly Chronic Pain and Opioid Management TeleECHO Clinic (ECHO Pain), which included pain and addiction didactics, case-based learning, and evidence-based recommendations. ECHO Pain sessions were offered 46 weeks per year. Attendance ranged from 1 to 3 sessions (47.7%), 4–19 (32.1%, or > 20 (20.2%).Main MeasuresThis study assessed whether clinician participation in Army and Navy Chronic Pain and Opioid Management TeleECHO Clinic (ECHO Pain) resulted in decreased prescription rates of opioid analgesics and co-prescribing of opioids and benzodiazepines. Measures included opioid prescriptions, morphine milligram equivalents (MME), and days of opioid and benzodiazepine co-prescribing per patient per year.Key ResultsPCCs participating in ECHO Pain had greater percent declines than the comparison group in (a) annual opioid prescriptions per patient (− 23% vs. − 9%, P < 0.001), (b) average MME prescribed per patient/year (−28% vs. −7%, p < .02), (c) days of co-prescribed opioid and benzodiazepine per opioid user per year (−53% vs. −1%, p < .001), and (d) the number of opioid users (−20.2% vs. −8%, p < .001). Propensity scoring transformation–adjusted results were consistent with the opioid prescribing and MME results.ConclusionsPatients treated by PCCs who opted to participate in ECHO Pain had greater declines in opioid-related prescriptions than patients whose PCCs opted not to participate.Electronic supplementary materialThe online version of this article (10.1007/s11606-018-4710-5) contains supplementary material, which is available to authorized users.

Background Heat acclimation and acclimatisation (HA) is typically used to enhance tolerance to the heat, thereby improving performance. HA might also confer a positive adaptation to maximal oxygen consumption ($$V{\text{O}}_{2\max }$$ V O 2 max ), although this has been historically debated and requires clarification via meta-analysis. Objectives (1) To meta-analyse all studies (with and without control groups) that have investigated the effect of HA on $$V{\text{O}}_{2\max }$$ V O 2 max adaptation in thermoneutral or hot environments; (2) Conduct meta-regressions to establish the moderating effect of selected variables on $$V{\text{O}}_{2\max }$$ V O 2 max adaptation following HA. Methods A search was performed using various databases in May 2020. The studies were screened using search criteria for eligibility. Twenty-eight peer-reviewed articles were identified for inclusion across four separate meta-analyses: (1) Thermoneutral $$V{\text{O}}_{2\max }$$ V O 2 max within-participants (pre-to-post HA); (2) Hot $$V{\text{O}}_{2\max }$$ V O 2 max within-participants (pre-to-post HA); (3) Thermoneutral $$V{\text{O}}_{2\max }$$ V O 2 max measurement; HA vs. control groups; (4) Hot $$V{\text{O}}_{2\max }$$ V O 2 max measurement, HA vs. control groups. Meta-regressions were performed for each meta-analysis based on: isothermal vs. iso-intensity programmes, days of heat exposure, HA ambient temperature (°C), heat index, HA session duration (min), ambient thermal load (HA session x ambient temperature), mean mechanical intensity (W) and the post-HA testing period (days). Results The meta-analysis of pre–post differences in thermoneutral $$V{\text{O}}_{2\max }$$ V O 2 max demonstrated small-to-moderate improvements in $$V{\text{O}}_{2\max }$$ V O 2 max (Hedges’ g = 0.42, 95% CI 0.24–0.59, P < 0.001), whereas moderate improvements were found for the equivalent analysis of hot $$V{\text{O}}_{2\max }$$ V O 2 max changes (Hedges’ g = 0.63, 95% CI 0.26–1.00, P < 0.001), which were positively moderated by the number of days post-testing (P = 0.033, β = 0.172). Meta-analysis of control vs. HA thermoneutral $$V{\text{O}}_{2\max }$$ V O 2 max demonstrated a small improvement in $$V{\text{O}}_{2\max }$$ V O 2 max in HA compared to control (Hedges’ g = 0.30, 95% CI 0.06–0.54, P = 0.014) and this effect was larger for the equivalent hot $$V{\text{O}}_{2\max }$$ V O 2 max analysis where a higher (moderate-to-large) improvement in $$V{\text{O}}_{2\max }$$ V O 2 max was found (Hedges’ g = 0.75, 95% CI 0.22–1.27, P = 0.005), with the number of HA days (P = 0.018; β = 0.291) and the ambient temperature during HA (P = 0.003; β = 0.650) positively moderating this effect. Conclusion HA can enhance $$V{\text{O}}_{2\max }$$ V O 2 max adaptation in thermoneutral or hot environments, with or without control group consideration, by at least a small and up to a moderate–large amount, with the larger improvements occurring in the heat. Ambient heat, number of induction days and post-testing days can explain some of the changes in hot $$V{\text{O}}_{2\max }$$ V O 2 max adaptation.