The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis

Immediate effects of superficial dry needling of the trigeminal nerve innervation field for participants with cervicogenic headache. A randomized controlled trial

BACKGROUND

Cervicogenic headache (CGH) is a common condition with a neuroanatomical basis involving the trigeminal nerve. Dry needling (DN) is a safe and effective treatment for CGH but most studies involve deep DN to cervical musculature.

OBJECTIVE

The aim of this study was to investigate immediate effects of superficial DN of the trigeminal nerve innervation field on numeric pain rating scale (NPRS), flexion-rotation test (FRT), cervical range of motion (AROM), and pain-pressure threshold (PPT) of right (R) and left (L) supraorbital (SO), and right (R) and left (L) greater occipital (GO) nerves in participants with CGH.

METHODS

A parallel controlled randomized design involving 30 participants with CGH received either superficial DN (N = 17) or sham DN (N = 13). Participants and outcome assessors were blind to group assignment. Wilcoxon signed rank analyzed within-group effects and Mann-Whitney U analyzed between-group.

RESULTS

Statistically significant between-group differences were observed for NPRS (P < .001) and AROM (P < .006) favoring DN and were clinically meaningful. Right and left Flexion rotation tests (FRT) outcomes were non-significant (P = .137) but clinically meaningful. No differences were observed for PPT over: R SO (P = .187); L SO (P = .052); R GO (P = .187); or L GO (P = .052). Between-group effect sizes across variables were moderate to large (0.53-1.4) but confidence intervals were wide.

CONCLUSION

Superficial DN targeting the innervation field of the trigeminal nerve improves clinical outcomes in patients with CGH. Only the immediate effects were analyzed and the sample size was small. Larger, longer-term assessments are needed comparing superficial DN of the trigeminal innervation field and other conservative interventions for CGH.

Lack of standardization in dry needling dosage and adverse event documentation limits outcome and safety reports: a scoping review of randomized clinical trials

OBJECTIVES

Examine: (1) whether variability in dry needling (DN) dosage affects pain outcomes, (2) if effect sizes are clinically important, and (3) how adverse events (AE) were documented and whether DN safety was determined.

METHODS

Nine databases were searched for randomized controlled trials (RCTs) investigating DN in symptomatic musculoskeletal disorders. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Included RCTs met PEDro criteria #1 and scored > 7/10. Data extraction included DN dosage, pain outcome measures, dichotomous AE reporting (yes/no), and AE categorization. Clinically meaningful differences were determined using the minimum clinically important difference (MCID) for pain outcomes .

RESULTS

Out of 22 identified RCTs, 11 demonstrated significant between-group differences exceeding the MCID, suggesting a clinically meaningful change in pain outcomes. Nine documented whether AE occurred. Only five provided AEs details and four cited a standard means to report AE.

DISCUSSION

There was inconsistency in reporting DN dosing parameters and AE. We could not determine if DN dosing affects outcomes, whether DN consistently produces clinically meaningful changes, or establish optimal dosage. Without more detailed reporting, replication of methods in future investigations is severely limited. A standardized method is lacking to report, classify, and provide context to AE from DN. Without more detailed AE reporting in clinical trials investigating DN efficacy, a more thorough appraisal of relative risk, severity, and frequency was not possible. Based on these inconsistencies, adopting a standardized checklist for reporting DN dosage and AE may improve internal and external validity and the generalizability of results.

Correlation between thoracic kyphosis and dry needle length required to reach the pleural space needling the upper trapezius: A cadaveric fluoroscopic assessment

BACKGROUND

It is unknown whether greater prone thoracic kyphosis increases pneumothorax risk during upper trapezius dry needling.

OBJECTIVES

To fluoroscopically assess for a correlation between prone thoracic kyphosis and needle length required to reach the pleural space dry needling the upper trapezius in prone.

DESIGN

Cadaveric study.

METHODS

Prone thoracic kyphosis was assessed using dual bubble inclinometers. A 30 mm dry needle was inserted into the midsubstance of the upper trapezius perpendicular to the thoracic kyphosis. A single C-arm fluoroscopic image was obtained. This procedure was repeated with 40, 50, and 60 mm needles. Images were independently viewed by a radiologist to make a binary decision (yes vs. no) whether the needle had potentially broached the pleural space.

RESULTS

Fifteen cadaveric specimens with a mean age of 74.9 ± 9.7 and mean kyphosis of 21.5° ±7.7 were used. A 30 mm needle never reached the pleural space. The pleural space was potentially broached on one, four and six occasions by the 40, 50, and 60 mm needle respectively. The correlation between needle depth penetration and kyphosis was not significant (r = 0.03, p = 0.93). Longer needles (50 and 60 mm) were significantly (p = 0.0049) more likely to reach the pleural space than shorter needles (30 and 40 mm).

CONCLUSION

Thoracic kyphosis was not correlated with needle length required to reach the pleural space. Clinicians may consider selecting shorter needles (<40 mm) to mitigate potential risk while dry needling the upper trapezius in prone.

The Application of Image Texture Analysis Techniques on the Effects of Dry Needling versus Placebo in Low-Back Pain Patients: A Pilot-Study

Low back pain is the leading cause of disability in the world, with a significant socio-economic impact. Deep dry needling is effective in the treatment of this pain, and it is one of the techniques preferred by physiotherapists. In this field, the use of ultrasound provides information of interest such as length, thickness, diameter, cross-sectional area, or muscle volume, among others. Objective: To find out whether the tissue changes (thickness, histogram, and contraction rate) that occur in the lumbar multifidus after application of the deep dry needle are related to changes in the pain and the disability of the patient. Design: Randomized, double-blind, parallel-group clinical trial. Setting: University of Alcalá, Department of Physiotherapy. Subjects: 21 voluntary patients (women and men) with non-specific low-back pain aged 18–65 years. Intervention: Patients were randomly divided into two groups. One group received dry needling and the other group a dry needling placebo. Initial post-needling and one week post-needling assessments were performed by a therapist blinded to the intervention. Variables: Lumbar multifidus thickness measured by RUSI, contraction time measured by M-mode, histograms measured by image analysis, muscle area, pain measured by VAS, pressure pain threshold measured by pressure algometer, and disability measured by Roland–Morris questionnaire. Conclusions: The contraction speed, resting thickness, and pain demonstrated significant differences within each group, but not between groups. There were significant differences in contraction ratio and in PPT between groups. There was excellent intra-examiner reliability in image collection for histogram analysis. Histogram analysis showed no significant differences between groups and measurements, neither for the parameters nor for the parameters combined with the outcome variables. A robust method for the image texture analyses in future histogram muscle analyses has been performed.

The role of acupuncture for myofascial pain syndrome (MPS) in interventional pain management

OBJECTIVES

The aim of this literature review is to describe the role of acupuncture for myofascial pain syndrome in interventional pain management.

CONTENT

Myofascial pain syndrome (MPS) can be found at all ages. Approximately 30.0-93.0% of patients with musculoskeletal pain have MPS. Unsuccessful treatment can lead to dysfunction, disability, and a cost burden. We conducted a search of studies published in Google Scholar and PubMed databases from 2016 to 2021.

SUMMARY

Acupuncture, combined with other therapies, is effective in reducing pain and improving physical function. Acupuncture can enhance endogenous opioids such as endorphins to relieve pain and enhance the healing process.

OUTLOOK

Acupuncture could be considered as one of nonpharmacological options in Interventional Pain Management for MPS. Interventions with acupuncture are safe and have minimal side effects when performed by a trained and competent practitioner.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

Short-term effectiveness of high- and low-intensity percutaneous electrolysis in patients with patellofemoral pain syndrome: A pilot study

BACKGROUND

Unilateral patellofemoral pain syndrome (PFPS) is the most frequently diagnosed knee condition in populations aged < 50 years old. Although the treatment of myofascial trigger points (MTrPs) is a common and effective tool for reducing pain, previous studies showed no additional benefits compared with placebo in populations with PFPS. Percutaneous electrolysis is a minimally invasive approach frequently used in musculotendinous pathologies which consists of the application of a galvanic current through dry needling (DN).

AIM

To evaluate changes in sensitivity, knee pain perception and perceived pain during the application of these three invasive techniques.

METHODS

A triple-blinded, pilot randomized controlled trial was conducted on fifteen patients with unilateral PFPS who were randomized to the high-intensity percutaneous electrolysis (HIPE) experimental group, low-intensity percutaneous electrolysis (LIPE) experimental group or DN active control group. All interventions were conducted in the most active MTrP, in the rectus femoris muscle. The HIPE group received a 660 mA galvanic current for 10 s, the LIPE group 220 mA × 30 s and the DN group received no galvanic current. The MTrP and patellar tendon pain pressure thresholds (PPTs) and subjective anterior knee pain perception (SAKPP) were assessed before, after and 7 d after the single intervention. In addition, perceived pain during the intervention was also assessed.

RESULTS

Both groups were comparable at baseline as no significant differences were found for age, height, weight, body mass index, PPTs or SAKPP. No adverse events were reported during or after the interventions. A significant decrease in SAKPP (both HIPE and LIPE, P < 0.01) and increased patellar tendon PPT (all, P < 0.001) were found, with no differences between the groups (VAS: F = 0.30; η2 = 0.05; P > 0.05; tendon PPT immediate effects: F = 0.15; η2 = 0.02; P > 0.05 and tendon PPT 7-d effects: F = 0.67; η2 = 0.10; P > 0.05). A significant PPT increase in rectus femoris MTrP was found at follow-up in both the HIPE and LIPE groups (both, P < 0.001) with no differences between the groups (immediate effects: F= 1.55; η2 = 0.20; P > 0.05 and 7-d effects: F = 0.71; η2 = 0.10; P > 0.05). Both HIPE and LIPE interventions were considered less painful compared with DN (F = 8.52; η2 = 0.587; P < 0.01).

CONCLUSION

HIPE and LIPE induce PPT changes in MTrPs and patellar tendon and improvements in SAKPP, and seem to produce less pain during the intervention compared with DN.

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

The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.

Effects of Dry Needling on Spasticity and Range of Motion: A Systematic Review

IMPORTANCE

This systematic review summarizes existing studies on dry needling for spasticity and range of motion (ROM) and discusses its potential for use as an occupational therapy intervention.

OBJECTIVE

To examine existing studies on the effects of dry needling on spasticity and ROM.

DATA SOURCES

Article citations and abstracts from Scopus, Cochrane Library, PubMed, CINAHL, and a university library search.

STUDY SELECTION AND DATA COLLECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in abstracting data. Peer-reviewed journal articles published in English between January 2007 and June 2019 were searched. Of 270 identified studies, 10 met the inclusion criteria. Studies were divided into categories on the basis of outcome measures (Modified Modified Ashworth Scale and ROM). Pain outcome measures were excluded because a systematic review addressing this outcome has recently been completed.

FINDINGS

Strong evidence was found to support the use of dry needling to decrease spasticity and increase ROM.

CONCLUSIONS AND RELEVANCE

This systematic review suggests that dry needling is an effective physical agent modality to decrease spasticity and increase ROM, both of which are potentially beneficial to functional outcomes.

WHAT THIS ARTICLE ADDS

This article provides information that may be helpful in determining the appropriateness of dry needling as an occupational therapy intervention.

Rate and maintenance of improvement of myofascial pain with dry needling alone vs. dry needling with intramuscular electrical stimulation: a randomized controlled trial

STUDY DESIGN

Prospective, randomized.

OBJECTIVES

To determine the difference in rate and maintenance of improvement of pain and disability for Dry Needling (DN) compared to Dry Needling with Intramuscular Electrical Stimulation (DN/IMES), in Myofascial Pain Syndrome (MPS).

BACKGROUND

DN and neuromuscular electrical stimulation (NMES) have been shown to be efficacious in treating MPS. DN/IMES for MPS treatment has not been studied extensively, but initial results are promising.

METHODS

Forty-five subjects were randomly assigned to the DN (n = 25) or DN/IMES (n = 20) group. Both groups received six consecutive weekly treatments and completed NDI and NPRS questionnaires (week 0, 3, 6, and 12).

RESULTS

Both DN and DN/IMES groups showed significant improvement between weeks 0-6 on NDI (p = 0.008 and 0.00002, respectively) and NPRS scores (0 = 0.017 and p = 0.018, respectively). DN/IMES group showed significant within group changes on the NPRS between weeks 0-3 (p = 0.029). No changes were noted in the DN or DN/IMES groups between week 6-12 on NDI (p = 0.497 and p = 0.714, respectively) or NPRS (p = 0.801 and p = 0.164, respectively).

CONCLUSION

DN and DN/IMES demonstrated improvement and maintenance in disability and pain for 6 weeks. No differences in improvement of disability or pain existed between the groups at week 6 or 12.

Trigger point dry needling, manual therapy and exercise versus manual therapy and exercise for the management of Achilles tendinopathy: a feasibility study

OBJECTIVES

The effects of trigger point dry needling (TDN) on myofascial trigger points (MTP) in Achilles tendinopathy (AT) are unknown. We conducted a study to test the feasibility of a large randomized controlled trial (RCT) to compare the effects of TDN to MT and exercise in a patient population with AT.

METHODS

Twenty-two subjects were randomly assigned to a control (MT+Ex) or experimental group (TDN+MT+Ex) and completed eight treatment sessions over 4 weeks with follow up at 3 months. TDN was performed to MTPs in the gastrocnemius, soleus or tibialis posterior each session. The same MT and exercise program was conducted in both groups.

RESULTS

Two of three criteria for feasibility were met. The attrition rate at 4-week and 3-month follow-up was 18.1% and 68%, respectively. Significant differences (p < .05) reported for within group analysis for FAAM, NPRS, pain pressure threshold and strength in both groups at 4 weeks and 3 months. The GROC was significant for MT + Ex at 3 months. No between group differences were found.  The MCID for the FAAM, GROC was surpassed in both groups at 4 weeks and 3 months and NPRS for the MT + Ex group at 4 weeks.

DISCUSSION

A large RCT to investigate the effects of TDN on MTP in AT is not feasible without modifications due to low recruitment and high attrition rate. Modifications to study design should give consideration for closed or national health-care system for access to large patient populations and reduced financial burden to subjects.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03261504F.

Short-Term Effects of PENS versus Dry Needling in Subjects with Unilateral Mechanical Neck Pain and Active Myofascial Trigger Points in Levator Scapulae Muscle: A Randomized Controlled Trial

Procedures such as dry needling (DN) or percutaneous electrical nerve stimulation (PENS) are commonly proposed for the treatment of myofascial trigger points (MTrP). The aim of the present study is to investigate if PENS is more effective than DN in the short term in subjects with mechanical neck pain. This was an evaluator-blinded randomized controlled trial. Subjects were recruited through announcements and randomly allocated into DN or PENS groups. Pain intensity, disability, pressure pain threshold (PPT), range of motion (ROM), and side-bending strength were measured. The analyses included mixed-model analyses of variance and pairwise comparisons with Bonferroni correction. The final sample was composed of 44 subjects (22 per group). Both groups showed improvements in pain intensity (ηp2 = 0.62; p < 0.01), disability (ηp2 = 0.74; p < 0.01), PPT (ηp2 = 0.79; p < 0.01), and strength (ηp2 = 0.37; p < 0.01). The PENS group showed greater improvements in disability (mean difference, 3.27; 95% CI, 0.27-6.27) and PPT (mean difference, 0.88-1.35; p < 0.01). Mixed results were obtained for ROM. PENS seems to produce greater improvements in PPT and disability in the short term.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.