mise à jour du
11 juin 2009
European Journal of Neurology
Excessive yawning induced
by stimulation of myofascial trigger point
CC Chang and ST. Chang
Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, Taipei, Taiwan


We describe a 44-year-old female patient with unusually severe muscle tightness in upper trapezius, levator scapulae, scalenes and the suboccipital extensors pain, which are ascribable to subcutaneous posterior cervical and thoracic trigger points. She was referred to our department for further rehabilitation therapy because of the muscle pain, which was in accordance with marked hyperesthesia, but without referred (distant) pain. She had no history of hypertension, diabetes mellitus, dyslipidemia or cardiac arrhythmia. There were no specific illnesses in her family background.
Results of all laboratory tests were within normal limits. A possible contribution might come from the preexisting degenerative change of cervical spine found on the plain films. Maneuver of self-myofascial release (SMR) together with stretching exercise learned from our therapist was used to improve myofascial restrictions and to restore soft-tissue extensibility.
Interestingly, several days later, excessive yawning developed when- ever she was performing SMR in our physiotherapy room (Fig). The patient signed informed consent for the publication of her photographs for the purposes of this research report.
Myofascial pain syndrome (MPS), a kind of non-articular musculoskeletal problem, is a painful condition associated with regional pain and muscle tenderness depicted by the presence of myofascial trigger points (MTPs) with hypersensitive nodules. The signs and symptoms associated with MPS include taut muscular bands, palpable nodules, pain are exacer- bated by stress and referred pain patterns.
There has been no consensus to diagnose the criteria of MPS, but it is commonly agreed that pain is a significant manifestation arising from MTPs. MTPs are manifested as focal muscle contracture on which pressure induces pain and twitching responses.
With regard to the treatment of MTPs, the therapeutic effect on the muscle contractions has been suggested to be due to stretch and relaxation of the involved deep muscle fibers possibly resolving the local ischemia postulated as underlying cause of the pain. Considering another treatment, the SMR is a technique used to mitigate myofascial restrictions and restore the extensible structure of soft-tissue.
Niddam et al. have recently provided evidence that the intervention of MTP at least partially involves supraspinal pain control via midbrain periaquaduct gray (PAG). In addition, van der Plas et al. suggested the PAG involving in the hypotensive pathway can be activated by the electrical stimulation of hypothalamic areas. The above points of view imply that the central modulation of pain evoked from MTP might be connected to excessive yawning via spinothalamic tract, PAG and hypothalamus.
Regarding the relationship between excessive yawning and thermoregulation, excessive yawning has been noted as a symptom of abnormal thermoregulation influenced by hypothalamus. However, further research should be performed to identify the possible connection between specific thermal responsiveness of ventromedial hypothalamic neurons and yawning induced by the stimulation of MTPs in addition to the nonthermal-related excessive yawning.
Excessive yawning shown in the patients series of photos obtained whenever she is performing self-myofascial release.
When she yawned, she squeezed her eyes tightly shut with her jaw tightened, nostrils flared as her mouth stretches open wide followed by a satisfied sigh with her eyes watered.
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