Current advances and novel research on minimal invasive techniques for musculoskeletal disorders

Placebo and nocebo effects of percutaneous needle electrolysis and dry-needling: an intra and inter-treatment sessions analysis of a three-arm randomized double-blinded controlled trial in patients with patellar tendinopathy

Objective

This study aimed to investigate the influence of potential placebo and nocebo effects on pain perception of percutaneous needle electrolysis (PNE) in individuals with patellar tendinopathy.

Methods

In this secondary analysis of a three-arm randomized double-blinded controlled trial, intra and inter-session pain perception data from 48 sporting participants with patellar tendinopathy between 18 and 45 years were investigated. Participants were divided into 3 parallel groups: "no-sham group" [PNE intervention], "single-sham group" [sham PNE by using dry needling], and "double-sham group" [sham PNE by using sham needles]. Every group received 4 sessions of the needling therapies targeting the patellar tendon over 8 weeks and was instructed to perform a unilateral eccentric exercise program of the quadriceps muscle on the affected side. Clinical and needle-related pain was assessed before, during, and after each treatment session using a visual analog scale.

Results

No differences were found between groups intra- or inter-session in terms of pain reduction (P = 0.424) despite clinical pain decreased in all groups since the first treatment session (P < 0.001). Furthermore, although the double-sham group showed a lower percentage of participants reporting needle-related pain during needle intervention (P = 0.005), the needle-related pain intensity after needle intervention was similar between groups (P = 0.682). Moreover, there were no group differences for the duration of pain sensation after any needle intervention (P = 0.184), extending in many cases beyond 24 h.

Conclusion

Needling therapies for individuals with patellar tendinopathy are prone to elicit placebo effects regarding clinical pain and nocebo effects regarding needling-related pain. Clinicians and physical therapists treating musculoskeletal pain conditions should consider the added value and potential mechanisms of action before routinely using needle techniques.

Effects of Adding Four Sessions of Ultrasound-Guided Percutaneous Electrical Nerve Stimulation to an Exercise Program in Patients with Shoulder Pain: A Randomized Controlled Trial

Objective: Percutaneous electrical nerve stimulation (PENS) appears to be effective for the treatment of musculoskeletal pain. The aim of this trial was to investigate the effects on disability and pain, as well as on the psychological aspects of adding PENS into an exercise program in patients with subacromial pain syndrome. Methods: A randomized, parallel-group clinical trial was conducted. Sixty patients with subacromial pain were allocated into exercise alone (n = 20), exercise plus PENS (n = 20), or exercise plus placebo PENS (n = 20) groups. Patients in all groups performed an exercise program twice daily for 3 weeks. Patients allocated to the PENS group also received four sessions of ultrasound-guided PENS targeting the axillar and suprascapular nerves. Patients allocated to the exercise plus placebo PENS received a sham PENS application. The primary outcome was related disability (Disabilities of the Arm, Shoulder, and Hand, DASH). Secondary outcomes included mean pain, anxiety levels, depressive symptoms, and sleep quality. They were assessed at baseline, one week after, and one and three months after. An analysis was performed using intention-to-treat with mixed-models ANCOVAs. Results: The results revealed no between-group differences for most outcomes (related disability: F = 0.292, p = 0.748, n2p = 0.011; anxiety: F = 0.780, p = 0.463, n2p = 0.027; depressive symptoms: F = 0.559, p = 0.575, n2p = 0.02; or sleep quality: F = 0.294, p = 0.747, n2p = 0.01); both groups experienced similar changes throughout the course of this study. Patients receiving exercise plus PENS exhibited greater improvement in shoulder pain at one month than those in the exercise (Δ -1.2, 95%CI -2.3 to -0.1) or the placebo (Δ -1.3, 95%CI -2.5 to -0.1) groups. Conclusions: The inclusion of four sessions of ultrasound-guided PENS targeting the axillar and suprascapular nerves into an exercise program did not result in better outcomes in our sample of patients with subacromial pain syndrome at one and three months after treatment.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Preclinical efficacy of TZG in myofascial pain syndrome by impairing PI3K-RAC2 signaling-mediated neutrophil extracellular traps

Tianhe Zhuifeng Gao (TZG) shows a satisfying therapeutic efficacy in treating arthromyodynia, which shares similar etiology to myofascial pain syndrome (MPS). We herein aim to explore whether TZG could be a potential prescription for MPS therapy. An MPS rat model was successfully established presenting with reduced pain thresholds, abnormal local switch responses, etc., which was effectively reversed by TZG treatment externally. A transcriptome sequencing based on the active MTrPs samples of rats, combined with network analysis revealed that TZG might ameliorate the progression of MPS by impairing neutrophil extracellular traps (NETs) release through inhibiting PI3K-RAC2 signaling to reduce NADPH oxidase-originated ROS. Experimentally, the expression levels of inducers, biomarkers of NETs formation and vessel injury, and p-PI3K, p-P47, and RAC2 proteins were all significantly up-regulated in affected tissues, which were markedly reversed by TZG. Our results not only shed light into broadening the clinical indications of TZG, but benefit MPS therapy.

Precision and Safety of Ultrasound-Guided versus Palpation-Guided Needle Placement on the Patellar Tendon: A Cadaveric Study

For decades, needling interventions have been performed based on manual palpation and anatomic knowledge. The increasing use of real-time ultrasonography in clinical practice has improved the accuracy and safety of needling techniques. Although currently ultrasound-guided procedures are routinely used for patellar tendon pathology, e.g., during percutaneous electrolysis, the accuracy of these procedures is still unknown. This study used a cadaveric model to compare and evaluate both the accuracy and safety of ultrasound-guided and palpation-guided needling techniques for the patellar tendon. A total of five physical therapists performed a series of 20 needle insertion task each (n = 100), 10 insertions based on manual palpation (n = 50) and 10 insertions guided with ultrasound (n = 50) to place a needle along the interface between the patellar tendon and Hoffa's fat pad. All procedures were performed on cryopreserved knee specimens. Distance to the targeted tissue, time of the procedure, accurate rate of insertions, number of passes, and unintentional punctured structures between both applications (with and without ultrasound guiding) were compared. The results revealed higher accuracy (100% vs. 80%), a lower distance from needle to the targeted tissue (0.25 ± 0.65 vs. 2.5 ± 1.9 mm), longer surface of contact with the needle (15.5 ± 6.65 vs. 4.7 ± 7.5 mm), and a lower frequency of patellar tendon puncture (16% vs. 52%, p < 0.001) with the ultrasound-guided procedure as opposed to palpation-guided one. Nevertheless, the ultrasound-guided procedure took longer (54.8 ± 26.8 vs. 23.75 ± 15.4 s) and required more passes (2.55 ± 1.9 vs. 1.5 ± 0.95) to be conducted than the palpation-guided procedure (all, p < 0.001). According to these findings, the accuracy of invasive procedures applied on the patellar tendon is higher when conducted with ultrasound guidance than when conducted just on manual palpation or anatomical landmark. These results suggest that ultrasound could improve the clinical application of invasive procedures at the fat-patellar tendon interface. Due to the anatomical features of the targeted tissue, some procedures require this precision, so the use of ultrasound is recommended.

Correlation between Body Composition and Inter-Examiner Errors for Assessing Lumbar Multifidus Muscle Size, Shape and Quality Metrics with Ultrasound Imaging

Ultrasound imaging (US) is widely used in several healthcare disciplines (including physiotherapy) for assessing multiple muscle metrics such as muscle morphology and quality. Since measuring instruments are required to demonstrate their reliability, accuracy, sensitivity, and specificity prior to their use in clinical and research settings, identifying factors affecting their diagnostic accuracy is essential. Since previous studies analyzed the impact of sociodemographic but not body composition characteristics in US errors, this study aimed to assess whether body composition metrics are correlated with ultrasound measurement errors. B-mode images of the lumbar multifidus muscle at the fifth lumbar vertebral level (L5) were acquired and analyzed in 49 healthy volunteers by two examiners (one experienced and one novel). Cross-sectional area, muscle perimeter and mean echo intensity were calculated bilaterally. A multivariate correlation matrix was calculated for assessing the inter-examiner differences with body composition metrics. Results demonstrated excellent reliability (intraclass correlation coefficient, ICC > 0.9) for assessing the muscle cross-sectional area and perimeter, and good reliability for assessing the muscle shape and mean echo intensity (ICC > 0.7). Inter-examiner errors for estimating muscle size were correlated with participants' age (p value, p < 0.01), weight (p < 0.05), total and trunk lean mass (both, p < 0.01) and water volume (p < 0.05). Greater shape descriptors and mean brightness disagreements were correlated with older ages (p < 0.05) and total lean mass (p < 0.05). No correlations between age and body composition metrics were found (p > 0.05). This study found US to be a reliable tool for assessing muscle size, shape and mean brightness. Although aging showed no correlations with body composition changes in this sample, it was the main factor correlated with US measurement errors.

Protective action of ultrasound-guided electrolysis technique on the muscle damage induced by notexin in rats

It is known that exercise can be one of the causes of muscular damage. In recent times, physiotherapists and medical professionals have been employing USGET techniques to stimulate muscle recovery to improve its performance after the injury. We pretend to analyse if the Ultrasound-guided electrolysis (USGET) technique could reduce muscle damage, inflammation, and pain in the present study. Female Wistar rats were assigned to one of three different groups: control (C), notexin (NOT) and notexin with USGET (electrolysis at 6mA) (NOT+USGET). We used the USGT technique, based on electrical stimulation with a continuous current of 4 pulses at an intensity of 6 mA for 5 seconds, conveyed to the muscle. The response was tested with motor function tests. In these tests, we could observe an increase in time and foot faults when crossing a beam in the NOT group compared to C group rats. On the other hand, a significant decrease in both variables was detected in the NOT+USGET compared to the NOT group. Muscle power was measured with a grip strength test, obtaining far better performances in NOT+USGET rats when compared to NOT rats. Moreover, the USGET technique prevented the increase of pro-inflammatory proteins IL-6 and chemokines CCL3 (Chemokine (C-C motif) ligand 3), CCL4 (Chemokine (C-C motif) ligand 4), and CCL5 (Chemokine (C-C motif) ligand 5) with their receptor CCR5 (C-C chemokine receptor type 5), induced by notexin in the quadriceps. At the same time, the study evidenced a decrease in both CCR8 (C-C chemokine receptor type 5,) and NF-ᴋB (nuclear factor- ᴋB) expressions after USGET treatment. On the other hand, we obtained evidence that demonstrated anti-inflammatory properties of the USGET technique, thus being the increase in IL-10 (Interleukin 10) and IL-13 (Interleukin 13) in the NOT+USGET group compared to the NOT group. Furthermore, when applying NSGET after damage, an increase in anti-inflammatory mediators and reduction of pro-inflammatory mediators, which, overall, promoted muscle regeneration, was observed. These results support the idea that the NSGET technique improves muscle recovery after toxic damages, which would justify its employment.

The Efficacy of Instrumental Physical Therapy through Extracorporeal Shock Wave Therapy in the Treatment of Plantar Fasciitis: An Umbrella Review

(1) Background: Plantar fasciitis (PF) is the most common cause of heel pain in adults. Extracorporeal shockwave therapy (ESWT) is a minimally invasive treatments commonly used for treating PF. Our aim is to provide a complete overview of which treatments have been compared to ESWT, with a focus on the modalities that have been used. (2) Methods: A thorough search of the literature was performed on Medline via Pubmed, Cochrane Database of Systematic Reviews (CDSR) of the Cochrane Library and Physiotherapy Evidence Databases (PEDro) up to 18 November 2021. In the study were included only systematic reviews and meta-analysis in English language, published from 2010 to date. (3) Results: A total of 14 systematic reviews and meta-analysis were included in the umbrella review. A total of eight studies compared the efficacy of ESWT treatment with placebo, three studies compared ESWT with another therapy (two studies compared ESWT and corticosteroids, one study ESWT and ultrasound therapy), and three studies had more than one comparison. (4) Conclusions: When compared to placebo, ESWT demonstrated to be effective. More randomized trials with specific comparisons between different types and intensity of SW are needed to obtain more precise information on SW effectiveness.

Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approaches at the Arcade of Frohse: A Potential Treatment for Radial Tunnel Syndrome

Entrapment of the radial nerve at the arcade of Frohse could contribute to symptoms in patients with lateral epicondylalgia or radial tunnel syndrome. Our aim was to determine the validity of applying percutaneous electrolysis, targeting the supinator muscle at the Frohse’s arcade with ultrasound imaging and in a Thiel-embalmed cadaver model (not ultrasound-guiding). Percutaneous electrolysis targeting the supinator muscle was conducted in five healthy volunteers (ultrasound study) and three Thiel-embalmed cadaver forearms. Two approaches, one with the forearm supinated and other with the forearm pronated were conducted. The needle was inserted until the tip reached the interphase of both bellies of the supinator muscle. Accurate needle penetration of the supinator muscle was observed in 100% in both US-imaging and cadaveric studies. No neurovascular bundle of the radial-nerve deep branch was pierced in any insertion. The distance from the tip of the needle to the neurovascular bundle was 15.3 ± 0.6 mm with the forearm supinated, and 11.2 ± 0.6 mm with the forearm pronated. The results of the current study support that percutaneous electrolysis can properly target the supinator muscle with either the forearm in supination or in pronation. In fact, penetration of the neurovascular bundle was not observed in any approach when percutaneous needling electrolysis was performed by an experienced clinician.

A Systematic Review of the Effectiveness of Dry Needling in Subacromial Syndrome

Simple Summary

Dry needling, used by physical therapists, is a treatment modality used for the management of musculoskeletal pain. It is a technique in which a fine needle is used to penetrate the skin, subcutaneous tissues and muscles, with the aim of mechanically disrupting the inner tissues. This technique is called dry needling as the procedure does not involve the injection of any substance. Subacromial syndrome is defined as any kind of non-traumatic, usually unilateral, shoulder problem that causes pain around the acromion, that usually gets worse during or after lifting the arm. It should not be treated with surgical methods as the first option, but with different physiotherapy techniques. In this review, an overview of the effects of dry needling combined with conventional physiotherapy in patients with subacromial syndrome is presented. One of the key focal points is that dry needling combined with physiotherapy is effective and safe in reducing the pain and disability caused by this pathology.

Abstract

Our aim was to evaluate the effectiveness of dry needling (DN) combined with conventional physiotherapy in the recovery of patients with subacromial syndrome (SAS). A search was made of the main open access health science databases. The publication date was not limited for systematic reviews but was for randomized clinical trials (RCTs), which were limited to the last five years (from 2016) in English or in Spanish. Ninety-four studies were selected. In order to assess the quality of the studies, the JADAD scale or Oxford quality scoring system was used. A total of 402 patients were analyzed in all the studies in which the application of conventional physiotherapy was compared to the DN, either in a combination or in isolation. Improvements were obtained in pain intensity (Visual Analogic Scale—VAS), Range of Movement (ROM), Pressure Pain Threshold (PPT), functionality with Disabilities of the Arm, Shoulder and Hand (DASH) and the Shoulder Pain and Disability Index (SPADI), and in the cost–benefit ratio. DN is effective and safe in reducing the pain and disability produced by SAS, with the best combination of treatment turning out to be conventional physiotherapy together with DN, obtaining more stable and longer-lasting benefits than merely applying the techniques in isolation.

Acute and Short-Term Effects of Dry Needling in Patients with Chronic Nonspecific Low Back Pain and Hamstring Tightness: A Pilot Study

BACKGROUND

Chronic nonspecific low back pain (LBP) is one of the common health issues. Hamstring tightness contributes to the development of LBP. This study aimed to investigate the acute and short-term effects of deep dry needling (DN) in patients with chronic nonspecific LBP and hamstring muscle tightness.

METHODS

A single-group pretest-posttest clinical study design was followed. The outcome measures were the visual analog scale (VAS), passive knee extension (PKE) test, finger-floor distance (FFD) test, and functional rating index (FRI). Patients underwent one session of deep DN of three points on both hamstring muscles, each point for one minute. Patients were assessed before (T0), immediately after (T1), and one week after DN (T2). The FRI was assessed at T0 and T2.

RESULTS

Ten women with a mean age of 21.1 years (SD = 1.6) participated in the study. Significant large effect sizes in VAS pain reduction (d = 1.25) and PKE hamstring tightness were obtained (hamstring: right, d = 0.82; left, d = 0.88) at T2. Medium effect sizes were obtained for FFD (d = 0.45) and FRI (d = 0.72) at T2.

CONCLUSION

A single session of deep DN improved pain and function and increased hamstring flexibility. This pilot study supports the use of DN in patients with LBP and hamstring tightness; however, future research with a rigorous study design of randomized controlled trial is required to confirm the findings. This trial is registered with IRCT20180511039612N1.