Comparative study of treatment interventions for patellar tendinopathy: a protocol for a randomised controlled trial

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.

The Effectiveness of Dry Needling Combined With Therapeutic Exercises in Treating Tendinopathy Conditions: A Systematic Review

CONTEXT

Approximately 70,000 Americans miss work annually due to tendinopathies causing pain, disability, and lower quality of life. Various conservative treatments have been demonstrated to improve outcomes in these conditions. Dry needling (DN) and therapeutic exercise are 2 such interventions that have been proposed to be a positive intervention for addressing tendinopathy.

OBJECTIVE

To summarize the best available evidence on the use of DN and exercise combined to treat tendinopathy.

EVIDENCE ACQUISITION

PubMed, EBSCOHost, and Web of Science were systematically searched from inception to March 2021. Articles were assessed to determine eligibility and evaluated for methodological quality using the PEDro scale. The PRISMA guidelines were used for this review. Inclusion criteria consisted of use of DN in combination with therapeutic exercise, human participants, and active tendinopathy pathology.

EVIDENCE SYNTHESIS

Seven studies met the inclusion and exclusion criteria, which averaged 6/11 on the PEDro scale. The level of agreement of evaluators was 94%. Current evidence supports the use of DN combined with therapeutic exercises, especially those including eccentric exercises, can improve pain and function for various tendinopathies. However, limited evidence exists regarding specific therapeutic interventions to be combined with DN.

CONCLUSION

There is moderate, level B evidence to suggest the use of DN techniques targeted at the tendon and combined with eccentric therapeutic exercise to improve pain and functional outcomes for tendinopathies.

Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

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Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon.

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This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone.

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Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time.

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In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.

Effectiveness of Ultrasound-Guided Percutaneous Electrolysis for Musculoskeletal Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects of ultrasound-guided percutaneous electrolysis alone or as an adjunct to other interventions on pain and pain-related disability for musculoskeletal pain conditions.

DATABASES AND DATA TREATMENT

Search of MEDLINE database, Allied and Complementary Medicine Database, EMBASE database, Cumulative Index to Nursing & Allied Health Literature database, EBSCO database, PubMed database, Physiotherapy Evidence Database, Cochrane Library database, Scopus database, and Web of Science database. Randomized controlled trials in which at least one group received ultrasound-guided percutaneous electrolysis for treatment of musculoskeletal pain. To be eligible, studies had to include humans and collect outcomes on pain intensity and pain-related disability for musculoskeletal pain syndromes. Data were extracted by two reviewers. The risk of bias was assessed by the Cochrane Guidelines and the quality of evidence was reported using the Grading of Recommendations Assessment, Development and Evaluation approach. Standardized mean differences (SMDs) and random effects were calculated.

RESULTS

Ten studies were included. The meta-analysis found that ultrasound-guided percutaneous electrolysis reduced the mean pain intensity by -2.06 (95% confidence interval [CI], -2.69 to -1.42) and the pain intensity as assessed with a visual analog scale or a numeric pain rating scale with a large size effect (SMD = -1.15; 95% CI, -1.48 to -0.81) and also improved pain-related disability with a large size effect (SMD = 0.95; 95% CI, 0.73-1.18) as compared with comparison groups. No differences in effect sizes were found among the short-term, midterm, and long-term follow-ups. The risk of bias was generally low, but the heterogeneity of the overall result downgraded the evidence level. Trials included heterogeneous musculoskeletal pain conditions and short-term, midterm, and long-term follow-ups.

CONCLUSION

Moderate evidence suggests positive effects of ultrasound-guided percutaneous electrolysis for pain and pain-related disability in musculoskeletal pain conditions relative to a comparison group in the short term, midterm, and long term.

A Comparative Study of Treatment Interventions for Patellar Tendinopathy: A Randomized Controlled Trial

OBJECTIVES

To determine the additional effect of dry needling (DN) or percutaneous needle electrolysis (PNE) combined with eccentric exercise (EE) and determine which is the most effective for patients with patellar tendinopathy (PT).

DESIGN

Blinded, randomized controlled trial, with follow-up at 10 and 22 weeks.

SETTINGS

Recruitment was performed in sport clubs. Diagnosis and intervention were conducted at San Jorge University.

PARTICIPANTS

Patients (N=48) with PT with pain for at least 3 months between the ages of 18 and 45 years.

INTERVENTIONS

Three interventions were carried out: DN and EE, PNE and EE, and EE with sham needle as the control group.

MAIN OUTCOME MEASURES

Disability was measured using the Victorian Institute of Sports Assessment Questionnaire, patellar tendon. Visual analog scale was used to measure pain over time, the Short Form-36 was used to measure quality of life, and ultrasound was used to measure structural abnormalities.

RESULTS

A total of 48 participants (42 men, 6 women; average age, 32.46y; SD, 7.14y) were enrolled. The improvement in disability and pain in each group between baseline and post-treatment and baseline and follow-up was significant (P≤.05), without differences among groups.

CONCLUSION

DN or PNE combined with an EE program has not shown to be more effective than a program of only EE to improve disability and pain in patients with PT in the short (10wk) and medium (22wk) terms. Clinical improvements were not associated with structural changes in the tendon.

The Effectiveness of Minimally Invasive Techniques in the Treatment of Patellar Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim was to determine the effectiveness of minimally invasive techniques (MIT) in patients with patellar tendinopathy. Database searches were performed for randomized controlled trials (RCTs) in electronic databases (WOS, Cochrane Central, SportDiscus, and Medline via PubMed and PEDro). The inclusion criteria used were published in English or Spanish and involving adults with patellar tendinopathy (pain on the inferior pole of the patella for a minimum of 3 months), with at least one group receiving MIT. The quality of the relevant RCTs was evaluated using the PEDro scale. The primary outcome was functionality using the VISA-p questionnaire. Secondary outcome was focused on pain. A total of 1164 studies were screened for possible inclusion in our systematic review. Finally, 10 RCTs were included with a total of 326 individuals. Five RCTs were included in the meta-analysis. The quality assessment revealed that all the studies included were considered to possess high methodological quality. All studies analyzing MIT such as platelet-rich plasma (PRP), dry needling, or skin-derived tenocyte-like cells, when combined with exercise, proved to be effective for patellar tendinopathy. Moreover, the PRP technique with doses greater than 4 mL together and combined with an exercise program lasting over 6 weeks obtained better results in functionality and pain than other treatments in the short term. However, in the long term, dry needling and skin-derived tenocyte-like cells are more effective than PRP. Although the infiltration of drugs was effective at posttreatment, these improvements were not maintained over time and may have secondary effects. Although there are no RCTs analyzing the effectiveness of MIT like percutaneous needle electrolysis, there has been an increasing number of publications achieving excellent results in the last years. However, it is necessary to develop RCTs analyzing not only the effect but also comparing the effectiveness between different MIT such as dry needling and percutaneous needle electrolysis.

Advanced diagnostic imaging and intervention in tendon diseases

Degenerative tendon pathology represents one of the most frequent and disabling musculoskeletal disorders. Diagnostic radiology plays a fundamental role in the clinical evaluation of tendon pathologies. Moreover, several minimally invasive treatments can be performed under imaging guidance to treat tendon disorders, maximizing the efficacy and reducing procedural complications. In this review article we describe the most relevant diagnostic features of conventional and advanced US and MRI imaging in tendon disorders, along with the main options for image-guided intervention. (www.actabiomedica.it)