Neuromuscular damage and repair after dry needling in mice

Coincidence between the distribution of myofascial trigger points and the presence of blood vessels in the gastrocnemius muscle: Implications for invasive procedures

PURPOSE

The gastrocnemius venous system presents different anatomical variants. There have been described four locations of myofascial trigger points (MTrPs) in this muscle. However, no studies have analyzed the coincidence between vessels and MTrPs present in the gastrocnemius. Therefore, the main objective was to study the anatomical variability of the venous system by ultrasound and its coincidence with the location of the MTrPs.

METHODS

A total of 100 lower limbs were studied. The gastrocnemius vessels were analyzed one by one by sector (medial, central, and lateral), quantifying the number of vessels, their distribution, and the coincidence with MTrPs.

RESULTS

All muscle heads showed at least one vessel per section. A large variability was observed, from one to eight vessels per muscle head, with the most frequent number being three in the gastrocnemius medialis and two in the gastrocnemius lateralis. In all cases, the location of the vessels coincided with the MTrPs.

CONCLUSIONS

The proximal gastrocnemius venous pattern is very variable between subjects in number of vessels and distribution, which has made it impossible to define a "safe" approach window for invasive procedures without ultrasound guidance. The coincidence between the clinical location of MTrPs of the gastrocnemius and the presence of vessels is total.

Is adding dry needling to a standard care protocol beneficial in patients with chronic neck pain? A randomized placebo-controlled trial

PURPOSE

To evaluate the short-term effects of adding a dry needling therapy to a standard care protocol based on education, exercise and electrotherapy, compared to a sham procedure and to a standard care protocol in isolation in patients with chronic neck pain.

MATERIAL AND METHODS

A randomized placebo-controlled trial was performed. The participants in the dry needling group received a standard care protocol based on patient education, therapeutic exercise and electrotherapy, as well as two sessions of dry needling in the upper trapezius, levator scapulae, and/or sternocleidomastoid muscles. The participants in the sham dry needling group received the same standard care protocol and two sessions of sham dry needling. The participants in the control group received the same standard care protocol. The outcomes measured were pain intensity, pressure pain threshold, neck disability, range of movement, activation of deep cervical flexor muscles, kinesiophobia, pain catastrophizing, anxiety, and depression.

RESULTS

No significant group by time interactions were found for any of the outcome variables except for lower cervical spine range of movement (F = 3.79; p = 0.030).

CONCLUSION

The addition of two sessions of dry needling in the superficial neck muscles to a standard protocol did not yield superior results compared to either the standard care alone or the standard care plus sham dry needling in patients with chronic neck pain in any outcome except for cervical range of movement.

Acute Effects of the Dry Needling Session on Gastrocnemius Muscle Biomechanical Properties, and Perfusion with Latent Trigger Points - A Single-Blind Randomized Controlled Trial in Mixed Martial Arts Athletes

The study aimed to evaluate the immediate effects of a dry needling (DN) therapy session on biomechanical properties, muscle power, perfusion, and pressure pain threshold of the gastrocnemius muscle with latent trigger points. Twenty mixed martial arts athletes (MMA) were randomly divided into two groups: experimental (eDN, n = 10) and sham (qDN, n = 10) to undergo one session of DN either with a real or a qazi needle. The measurements were taken at rest, 1-5 minutes after the DN (Post1-5min) and 24h after the DN (Post24h). DN significantly increased the muscle perfusion (Post1-5min and Post24h, p < 0.001), reduced its tone (Post1-5min and Post24h, p < 0.001) and stiffness (Post1-5min, p < 0.05; Post24 h, p < 0.001), and improved its elasticity (Post1-5min and Post24h, p < 0.001). DN also caused a significant increase in pressure pain threshold (Post1-5min, p < 0.001; Post24h, p < 0.05) and in muscle power (Post24h, p < 0.01). The DN session increased the blood perfusion and improved the biomechanical properties of the gastrocnemius muscle, which led to improved muscle power. The DN also had an analgesic effect. These effects were maintained at 24 h, which suggests that DN could facilitate muscle recovery in a post-exercise period of MMA athletes.

Shock waves as treatment of mouse myofascial trigger points

INTRODUCTION

An abnormal increase in spontaneous neurotransmission can induce subsynaptic knots in the myocyte called myofascial trigger points. The treatment of choice is to destroy these trigger points by inserting needles. However, 10% of the population has a phobia of needles, blood, or injuries. Therefore, the objective of this study is to verify the usefulness of shock waves in the treatment of myofascial trigger points.

METHODS

Two groups of mice have been developed for this: healthy muscles treated with shock waves; trigger points affected muscles artificially generated with neostigmine and subsequently treated with shock waves. Muscles were stained with methylene blue, PAS-Alcian Blue, and labeling the axons with fluorescein and the acetylcholine receptors with rhodamine. Using intracellular recording the frequency of miniature endplate potentials (mEPPs) was recorded and endplate noise was recorded with electromyography.

RESULTS

No healthy muscles treated with shock waves showed injury. Twitch knots in mice previously treated with neostigmine disappeared after shock wave treatment. Several motor axonal branches were retracted. On the other hand, shock wave treatment reduces the frequency of mEPPs and the number of areas with endplate noise.

DISCUSSION

Shock waves seem to be a suitable treatment for myofascial trigger points. In the present study, with a single session of shock waves, very relevant results have been obtained, both functional (normalization of spontaneous neurotransmission) and morphological (disappearance of myofascial trigger points). Patients with a phobia of needles, blood, or injuries who cannot benefit from dry needling may turn to noninvasive radial shock wave treatment.

Effects of Dry Needling on Spasticity in Multiple Sclerosis Evaluated Through the Rate-Dependent Depression of the H Reflex: A Case Report

Background

Spasticity is a common symptom of multiple sclerosis (MS) which affects mobility. Dry Needling (DN) has shown a reduction in spasticity in neuromuscular conditions such as stroke and spinal cord injury although the mechanism of action is still unclear. In spastic individuals, the Rate-Dependent Depression (RDD) of the H reflex is decreased as compared to controls and analyzing the effects of DN in the RDD may help to understand its mechanism of action.

Objective

To evaluate the effect of Dry Needling on spasticity measured by the Rate-dependent Depression (RDD) of the H reflex in an MS patient.

Methods

Three time points were evaluated: Pre-intervention (T1), Post-intervention assessments were carried out in the seventh week at two-time points: Before DN (T2) and After DN (T3). Main outcomes included the RDD and latency of the H reflex in the lower limbs at stimulation frequencies of 0.1, 1, 2, and 5 Hz in a five consecutive pulses protocol.

Results

An impairment of the RDD of the H reflex at frequencies ≥1 Hz was found. Statistically significant differences were found when comparing the mean RDD of the H reflex in Pre-intervention compared to Post-intervention at 1, 2, and 5 Hz stimulation frequencies. Mean latencies were statistically lower when comparing Pre- vs Post-intervention.

Conclusion

Results suggest a partial reduction in spasticity represented by decrease of the excitability of the neural elements involved in the RDD of the H reflex following DN. The RDD of the H reflex could be implemented as an objective tool to monitor changes in spasticity in larger DN trials.

Treadmill exercise post dry needling improves heel rise in patients recovering from surgical ankle fracture: A randomised controlled trial

INTRODUCTION

Little is known about the effectiveness of the dry needling technique (DNT) plus exercise on motor function in musculoskeletal diseases.

OBJECTIVE

To evaluate the effects of treadmill exercise immediately after DNT on pain, range of motion (ROM) and bilateral heel rise test in patients recovering from surgical ankle fracture.

METHOD

A randomised, parallel-group, controlled trial was conducted on patients recovering from surgical ankle fracture. Patients received the DNT intervention for the triceps surae muscle. Then, participants were randomly assigned to the experimental (DNT plus incline treadmill for 20 min) or control group (DNT plus rest for 20 min). Baseline and immediate post-intervention assessments included: visual analogue scale (VAS), maximal ankle dorsiflexion ROM and bilateral heel rise test.

RESULTS

A total of 20 patients recovering from surgical ankle fracture were included. Eleven patients were assigned to the experimental group (mean age 46 ± 12.6 years, 2/9 men/women) and nine to the control group (mean age 52 ± 13.4 years, 2/7 men/women). Two-way ANOVA showed a significant time × group interaction for bilateral heel rise test (F = 5.514, p = 0.030, ηp2 = 0.235). Both groups increased the number of repetitions (p < 0.001), however, the experimental group showed a significant difference compared to control group (mean difference: 2.73 repetitions; p = 0.030). There was no time × group interaction in VAS and ROM (p > 0.05).

CONCLUSION

Our results indicate that treadmill exercise after dry needling improves plantar flexors motor function more than rest after dry needling in patients with surgical ankle fracture.

Ultrasound-Guided Percutaneous Neuromodulation in Multiple Sclerosis: A Case Report

Multiple sclerosis is a degenerative inflammatory disease that causes different musculoskeletal problems. Its impact has led to the study of treatment alternatives such as the use of invasive physiotherapy. In this study, we analyze the effects of ultrasound-guided percutaneous neuromodulation to a 51-year-old man suffering from multiple sclerosis and an associated hemiparesis in the left upper limb. A dry needling needle was placed in contact with the median nerve under ultrasound guidance and 10 trains of 10 seconds of electrostimulation with a frequency of 10 Hz and an impulse width of 240 µs were applied, with 10 seconds of pause between them. There was a significant improvement in the grip strength immediately after the treatment which increased progressively at 24 hours and at 4 days follow-up. There was also an improvement in the hand function, with a decrease in the time necessary to perform the 9 Hole Peg Test immediately after the treatment, which was maintained at 24 hours and at 4 days follow-up. Future studies with larger samples are needed to further test the effects of this invasive physiotherapy technique as well as its possible applications to other neurological conditions.

Effects of dry needling intervention on lower limb dysfunction after stroke: study protocol for a randomised controlled trial

INTRODUCTION

Lower limb dysfunction is among the common sequelae of patients who had a poststroke and often results in the reduction of the quality of life. This study aims to assess the short and interim-term efficacy of dry needling (DN) intervention on lower extremity function, balance and gait in lower limb dysfunction after stroke.

METHODS AND ANALYSIS

This protocol entails an assessor and statistician-blinded, single-centre study with a randomised controlled trial. Forty-four patients who had a poststroke will be randomly allocated (1:1) to either the conventional treatment group (n=22) or the DN group (n=22). The conventional treatment group will receive conventional rehabilitation treatment once a day for 40 min each time. The treatment will be performed five times a week for 2 weeks. In the DN group, participants will be treated with DN on the basis of the conventional treatment. The intervention will be performed thrice a week for 2 weeks. The primary outcome that determines the efficacy of lower limb dysfunction will be the change in the Fugl-Meyer Assessment of Lower Extremity scale. The secondary indicators include the range of motion of knee and ankle joints, limits of stability, modified Clinical Test of Sensory Interaction on Balance, Timed Up and Go test, Modified Ashworth Scale and Barthel Index. Results will be evaluated at baseline, at 24 hours after intervention, at 2 weeks after intervention and at 3-month follow-up. Data will be released after the completion of the study. Adverse events will be reported.

ETHICS AND DISSEMINATION

The experiment was approved by the Ethical Committee of Shanghai Tong Ren Hospital in October 2021 (approval number: 202105702). The results of this study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000040754.

Intramuscular Electrical Stimulation to Trigger Points: Insights into Mechanisms and Clinical Applications—A Scoping Review

Intramuscular electrical stimulation (IMES) is a modality used by clinicians to treat myofascial pain. Recent studies have shown positive results for the use of IMES on pain outcomes, yet studies investigating the potential mechanisms of IMES directly to trigger points (TrPs) are lacking. We performed a scoping review of the literature to summarize the current evidence from human and animal studies on the mechanisms of IMES to the TrP location, and to identify gaps in the existing literature. Electronic literature searches were conducted across five databases from inception to 15 August 2022, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Scopus and Cochrane Register of Controlled Trials. Four studies met our full criteria for inclusion in this review. Three studies assessed the effects of IMES to TrPs on human subjects with MPS, and only one study used an animal model with experimentally generated TrPs. Based on the results of the included studies, IMES within a TrP region was reported to normalize muscle blood flow, decrease endplate noise of the TrP and elicit antinociceptive effects, at least partially, through engaging supraspinal descending pain inhibitory systems. At present, no clinical implications can be determined on the use of IMES to TrPs due to the limited amount and quality of the available evidence. Further studies investigating the clinical effectiveness and also underlying mechanisms of IMES to TrPs are clearly needed.

Effect of Dry Needling Treatment on Tibial Musculature in Combination with Neurorehabilitation Treatment in Stroke Patients: Randomized Clinical Study

(1) Background: Introducing ultrasound-guided dry needling to neurorehabilitation treatments increases the beneficial effects of therapy. The aim of this study was to compare the effects of including an ultrasound-guided dry needling session in neurorehabilitation treatment on spasticity and gait-balance quality versus neurorehabilitation treatment in subjects who had suffered a stroke. (2) Methods: A single-blind, randomized clinical trial was conducted. Thirty-six patients who had suffered a stroke in the right middle cerebral artery signed the informed consent for participation in the study. Twenty patients finally participated and were randomly assigned to the control group (neurorehabilitation treatment) or experimental group (neurorehabilitation treatment plus ultrasound-guided dry needling). Pre-treatment and post-treatment data were collected on the same day. The experimental group (n = 10) first underwent an ultrasound-guided dry needling intervention on the tibialis anterior and tibialis posterior musculature, followed by neurorehabilitation treatment; the control group (n = 10) underwent their corresponding neurorehabilitation without the invasive technique. Pre-treatment and post-treatment measurements were taken on the same day, assessing the quality of balance-gait using the "Up and Go" test and the degree of spasticity using the Modified Modified Ashworth Scale. (3) Results: The patients who received neurorehabilitation treatment plus ultrasound-guided dry needling showed a greater decrease in spasticity in the tibial musculature after the neurorehabilitation treatment session (p < 0.001), improving balance and gait (p < 0.001). (4) Conclusions: An ultrasound-guided dry needling session combined with neurorehabilitation treatment reduced spasticity and improved balance and gait in stroke patients.

Effectiveness of Dry Needling of Myofascial Trigger Points in the Triceps Surae Muscles: Systematic Review

This study aims to analyze the effects of Dry Needling (DN) for the release of myofascial trigger points (MTrPs) in the triceps surae muscles (TSM). A systematic review was performed up to February 2022 in PubMed, PEDro, Scopus, CENTRAL, and Web of Science. Selection criteria were studies involving subjects older than 18 years presenting MTrPs in the TSM, without any concomitant acute or chronic musculoskeletal conditions; DN interventions applied to the MTrPs of the TSM; and results on pain, range of motion (ROM), muscle strength, muscle stiffness, and functional outcomes. The PEDro scale was used to assess the methodological quality of the studies, and the Risk of Bias Tool 2.0 to assess risk of bias. A total of 12 studies were included in the systematic review, involving 426 participants. These results suggest that DN of MTrPs in TSM could have a positive impact on muscle stiffness and functional outcomes. There are inconclusive findings on musculoskeletal pain, ROM, and muscle strength. Significant results were obtained in favor of the control groups on pressure pain thresholds. Despite the benefits obtained on muscle stiffness and functional performance, the evidence for the use of DN of MTrPs in the TSM remains inconclusive.

Comparison of dry needling and self-stretching in muscle extensibility, pain, stiffness, and physical function in hip osteoarthritis: A randomized controlled trial

BACKGROUND AND PURPOSE

Patients with hip osteoarthritis (OA) present myofascial trigger points in the hip muscles that may reduce muscle extensibility, provoke pain and stiffness, and decrease physical function. The purpose of the study was to compare the effects of dry needling (DN) intervention with a self-stretching protocol on muscle extensibility, pain, stiffness, and physical function in patients with hip OA.

MATERIALS AND METHODS

A single-blinded randomised controlled trial was designed. Thirty-eight participants with hip OA were randomly assigned to the DN group (n = 19) or the stretching group (n = 19). The DN group received three sessions of DN, and the stretching group followed a 3-week protocol. Hip muscle extensibility was the primary outcome and was measured using the Ely test, the modified Ober test, and the Active Knee Extension test. Pain, stiffness, and physical function were the secondary outcomes measured with the WOMAC questionnaire. The variables were assessed before and after treatment by blinded examiners.

RESULTS

DN was more effective than self-stretching for improving hip flexor and abductor muscles extensibility (p < 0.05). DN and self-stretching techniques improved hip extensor muscles extensibility, pain, stiffness, and physical function in patients with hip OA (<0.05). The DN group showed large effect sizes in all the variables (d > 0.8).

CONCLUSION

Three sessions of DN were more effective than three weeks of self-stretching to improve hip muscle extensibility in patients with hip OA. DN and self-stretching techniques decreased pain and stiffness and improved physical function in patients with hip OA.

Dry Needling Produces Mild Injuries Irrespective to Muscle Stiffness and Tension in Ex Vivo Mice Muscles

Numerous studies have suggested that the myofascial trigger points are responsible for most of the myofascial pain syndrome, so it seems reasonable that its destruction is a good therapeutic solution. The effectiveness of dry needling (DN) has been confirmed in muscles with myofascial trigger points, hypertonicity, and spasticity. The objective of this study is to analyze the need of repetitive punctures on muscles in different situations. The levator auris longus (LAL) muscle and gastrocnemius muscle from adult male Swiss mice were dissected and maintained alive, while being submerged in an oxygenated Ringer’s solution. DN was evaluated under four animal models, mimicking the human condition: normal healthy muscles, muscle fibers with contraction knots, muscles submerged in a depolarizing Ringer solution (KCl-CaCl2), and muscles submerged in Ringer solution with formalin. Thereafter, samples were evaluated with optical microscopy (LAL) and scanning electron microscopy (gastrocnemius). Healthy muscles allowed the penetration of needles between fibers with minimal injuries. In muscles with contraction knots, the needle separated many muscle fibers, and several others were injured, while blood vessels and intramuscular nerves were mostly not injured. Muscles submerged in a depolarizing solution inducing sustained contraction showed more injured muscular fibers and several muscle fibers separated by the needle. Finally, the muscles submerged in Ringer solution with formalin showed a few number of injured muscular fibers and abundant muscle fibers separated by the needle. Scanning electron microscopy images confirm the optical analyses. In summary, dry needling is a technique that causes mild injury irrespective of the muscle tone.

Immediate Effect of Dry Needling on the Viscoelastic Properties of a Trigger Point on the Infraspinatus Muscle Measured with MyotonPRO

Purpose: This article investigates the immediate effects of a dry needling (DN) puncture on the viscoelastic properties (tone, stiffness, elasticity) of a trigger point (TP) in the infraspinatus muscle in non-traumatic chronic shoulder pain. Method: Forty-eight individuals with non-traumatic chronic shoulder pain were recruited. The presence of a TP in the infraspinatus muscle was confirmed by a standardized palpatory exam. The viscoelastic properties were measured with a MyotonPRO device at baseline (T1), immediately after DN (T2), and 30 minutes later (T3). A DN puncture was applied to the TP to obtain a local twitch response while performing the technique. Results: Analyses of variance showed significant decreases in tone ( p < 0.001) and stiffness ( p = 0.003) across time after the DN technique. Post hoc tests revealed a significant reduction in tone and stiffness from T1 to T2 ( p ≤ 0.004) and no significant changes from T2 to T3 ( p ≥ 0.10). At T3, only stiffness remained significantly lower compared to T1 ( p = 0.013). Conclusions: This study brings new insights on the immediate mechanical effect of DN on tone and stiffness of TPs. Whether these effects are associated with symptom improvement and long-term effects still needs to be verified.

Effects of dry needling on pain, disability, kinesiophobia, pain catastrophizing and psychological distress in patients with chronic neck pain: A randomized controlled pilot study

BACKGROUND

Myofascial trigger points (MTrPs) in neck muscles seem to be related to the main symptoms of patients with chronic neck pain.

OBJECTIVE

The objective was to investigate the effects of dry needling (DN) on pain, disability, kinesiophobia, pain catastrophizing and psychological distress in patients with chronic neck pain.

METHODS

A double blind randomized controlled pilot trial was designed. Twenty-one patients with chronic neck pain were randomly allocated to the DN group (n= 7), Sham-DN group (n= 7) or Control group (n= 7). All groups received a Transcutaneous Electrical Nerve Stimulation and Therapeutic Ultrasound (TENS/US) protocol with patient education. The DN and Sham-DN groups received two sessions of DN and sham DN, respectively. The primary outcome was pain intensity. Secondary outcomes were disability, kinesiophobia, pain catastrophizing, psychological distress, self-reported improvement and success of blinding.

RESULTS

The DN group showed a greater decrease in pain intensity, disability and pain catastrophizing compared to the Sham-DN group (p< 0.05) and the Control group (p< 0.05). The DN group showed the highest self-reported improvement.

CONCLUSION

Adding two sessions of DN in active MTrPs in upper trapezius, levator scapulae and sternocleidomastoid muscles to a TENS/US protocol with patient education decreased pain intensity, disability and pain catastrophizing in patients with chronic neck pain.

Effects of dry needling on function, hypertonia and quality of life in chronic stroke: a randomized clinical trial

BACKGROUND

Persons with stroke commonly have impairments associated with a reduction in functionality. Motor impairments are the most prevalent, causing an impact on activities of daily life.

OBJECTIVE

The aim of this study was to evaluate the effect of a session of dry needling (DN) applied to the upper extremity muscles on the sensorimotor function, hypertonia, and quality of life of persons with chronic stroke.

METHODS

A randomized, sham-controlled clinical trial was performed. Participants were randomly assigned into an intervention group that received a single session DN in the biceps brachii, brachialis, flexor digitorum superficialis and profundus, extensor digitorum, adductor pollicis and triceps brachii muscles, or into a control group that received the same treatment but with a sham DN intervention. Treatment outcomes included the Fugl-Meyer Assessment Scale for the upper extremity, the Modified Modified Ashworth Scale, and the EuroQol-5D questionnaire. Measurements were carried out before, immediately after, and 14 days after intervention.

RESULTS

Twenty-three persons participated in the study. Significant differences between groups were observed after the intervention in the total wrist-hand motor score (p = 0.023) and sensorimotor score (p = 0.022), for hypertonia in the elbow extensors both after treatment (p = 0.002) and at follow-up (p = 0.018), and in quality of life at follow-up (p = 0.030).

CONCLUSIONS

A single session of DN improved total wrist-hand motor function and total sensorimotor function in persons with chronic stroke immediately after treatment, as well as quality of life 2 weeks after treatment.

TRIAL REGISTRATION NUMBER

NCT03546517 (ClinicalTrials.gov).

The importance of the local twitch response during needling interventions in spinal pain associated with myofascial trigger points: a systematic review and meta-analysis

OBJECTIVE

To compare the clinical effects of needling interventions eliciting local twitch responses (LTRs) versus needling without eliciting LTRs when applied to muscle trigger points (TrPs) associated with spinal pain of musculoskeletal origin.

DATABASES AND DATA TREATMENT

Electronic databases were searched for randomized or non-randomized clinical trials where one group received needling intervention where LTRs were elicited and was compared with another group receiving the same intervention without elicitation of LTRs in spinal pain disorders associated with TrPs. Outcomes included pain intensity, pain-related disability, and pressure pain thresholds. The risk of bias (RoB) was assessed using the Cochrane risk of bias tool or ROBINS-I tool, methodological quality was assessed with the PEDro score, and quality of evidence was evaluated using the GRADE approach.

RESULTS

Six trials were included. The application of a needling intervention eliciting LTRs was associated with a significant reduction in pain intensity immediately after treatment (mean difference (MD): -2.03 points, 95% confidence interval (CI): -3.77 to -0.29; standardized MD (SMD): -1.35, 95% CI: -2.32 to -0.38, p = 0.02) when compared to the same needling intervention without elicitation of LTRs. No effect at short-term follow-up (MD: -0.20 points, 95% CI: -1.46 to 1.06, p = 0.75) was observed. No significant differences based on elicitation or non-elicitation of LTRs were found in related disability (SMD: -0.05, 95% CI: -0.41 to 0.30, p = 0.77) or pressure pain thresholds (MD: 23.39 kPa, 95% CI: -13.68 to 60.47, p = 0.22).

DISCUSSION

Low-level evidence suggests an immediate effect of obtaining LTRs during needling interventions on pain intensity, with no significant effects on related disability or pressure pain sensitivity in spinal pain disorders associated with muscle TrPs.

REGISTRATION NUMBER

OSF Registry-https://doi.org/10.17605/OSF.IO/5ZX9N.

Cost-effectiveness of upper extremity dry needling in the rehabilitation of patients with stroke

INTRODUCTION

Dry needling (DN) has been shown to be effective for the treatment of upper extremity hypertonia in patients with stroke.

PURPOSE

To evaluate the cost-effectiveness of DN in patients with stroke.

METHODS

A cost-effectiveness analysis was performed in a research study conducted at a Spanish public hospital where patients were classified into two groups with or without DN. Hypertonia was measured using the Modified Modified Ashworth Scale (MMAS), and quality of life (QOL) was assessed using the EuroQoL 5-dimension questionnaire. Data regarding the effects and costs of physiotherapy were presented by calculating the mean and 95% confidence interval. The health outcomes were evaluated considering the rate of responders to the treatment based on the MMAS. Spanish preference weights were used to estimate quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were calculated to determine the economic value of DN.

RESULTS

Eighty patients with stroke in the subacute stage of recovery were selected to participate in this study. Based on the rate of responders, the ICER of the DN group was very low. Despite the sensitivity analysis performed, the results of the ICUR were not encouraging.

DISCUSSION

Cost-effectiveness with responder rate results were favourable for the DN group and were confirmed by the sensitivity analysis according to levels of care. In addition, our findings revealed that 4 weeks of treatment could be more cost-effective than 8 weeks. DN treatment of the upper extremity appears to be cost-effective based on the rate of responders measured using the MMAS scale.

Effects of dry needling on mechanical and contractile properties of the upper trapezius with latent myofascial trigger points: A randomized controlled trial

BACKGROUND

Latent trigger point (LTrP) can cause motor dysfunction and disturb normal patterns of motor recruitment.

OBJECTIVE

To analyze the effects of DN in the upper trapezius (UT) LTrP on pain and the mechanical and contractile properties of the muscle.

DESIGN

A randomized, double-blinded, parallel-group-trial.

METHODS

Fifty healthy volunteers with LTrPs in the UT were randomly divided into a DN-group (n = 26) and a Sham-DN-group (n = 24) and received one session of DN or placebo treatment. Mechanical and contractile properties of the muscle and pressure pain perception (PPP) were evaluated before treatment and in a 30min, 24 h and 72 h follow-up after treatment.

RESULTS

In the mechanical properties, the DN-group showed lower values than the Sham-DN-group for dynamic stiffness at 72 h (p = 0.04). The DN-group showed lower values for dynamic stiffness at 72 h from baseline (278.74 ± 38.40 to 261.54 ± 33.64 N/m; p = 0.01) and for tone at 72 h from 30min (16.62 ± 1.27 to 15.88 ± 1.31 Hz; p = 0.01). In the contractile properties, the DN-group showed higher values for maximal radial displacement (Dm) of the muscle belly at 72 h from baseline (5.38 ± 1.67 to 6.13 ± 1.70 mm; p = 0.04), higher values for contraction time at 30min (28.53 ± 8.80 s; p = 0.03) and lower ones at 72 h (24.74 ± 4.36 s; p = 0.04) from baseline (26.97 ± 6.63 s). The DN-group showed a decrease of PPP from baseline to 72 h after treatment (5.16 ± 1.33 to 4.02 ± 0.97 mm; p < 0.01).

CONCLUSION

The application of DN in healthy volunteers over LTrPs in the UT decreased dynamic stiffness, tone and contraction time and increased Dm at 72 h after treatment. Additionally, the PPP showed a decrease at 72 h after needling. CLINICALTRIALS.GOV: NCT04466813.

Efficacy of Exercise on Postneedling Soreness: A Randomized Controlled Trial

This study aimed to investigate the efficacy of concentric, eccentric, and isometric exercise protocols on the postneedling soreness (PNS) after the dry needling (DN) of latent myofascial trigger points (MTrP) in the medial gastrocnemius muscle. A randomized clinical trial was carried out. Volunteers, ≥18 years old, with a latent MTrP in the medial gastrocnemius muscle were included. Subjects with contraindications to DN, active MTrPs, and/or other treatments in MTrPs in the 3 months prior to recruitment were excluded. A total of 69 participants were randomly allocated to four groups, where post-DN intervention consisted of an eccentric, concentric, or isometric exercise, or no exercise, and they were assessed for PNS intensity (visual analog scale (pVAS)), pressure pain threshold (PPT, analog algometer), pain intensity (nVAS), and local twitch responses (LTRs) during DN, as well as demographics and anthropometrics. The mixed-model analyses of variance showed significant interaction between time and pVAS, and between time and PPT (p < 0.001). While the multivariate test confirmed that PNS and PPT improved over time within each group, specifically between 6–12 h post-intervention, the post hoc analyses did not show significant differences between groups. The mixed-model analyses of covariance showed a significant nVAS effect (p < 0.01) on PNS decrease, and some effect of the LTRs (p < 0.01) and sex (p = 0.08) on PPT changes. All groups improved PNS and PPT, but none of them showed a greater improvement above the others. The most dramatic decrease was observed between 6–12 h post-exercise, although concentric and eccentric exercise had an effect immediately after the intervention. Between all potential modifiers, pain during DN significantly influenced PNS progression, while LTRs and sex seemed to determine PPT course over time.

Analysis and comparison of pain pressure threshold and active cervical range of motion after superficial and deep dry needling techniques of the upper trapezius muscle

OBJECTIVES

To evaluate the changes in pain pressure threshold (PPT) and active cervical range of motion (ACROM) after the application of superficial dry needling (DN) or deep DN in myofascial trigger point (MTrP) 1 of the upper trapezius versus a simulated DN technique in the gastrocnemius muscle (control group).

DESIGN

Double-blind, randomized controlled trial with 7-day follow-up.

PARTICIPANTS

Asymptomatic volunteers (n = 180; 76 men, 104 women) with a latent MTrP 1 in the upper trapezius were randomly divided into three groups: G1, receiving superficial DN in the upper trapezius; G2, receiving deep DN in the upper trapezius; and G3, control group, receiving simulated DN technique in the gastrocnemius muscle.

MAIN OUTCOME MEASURES

While sitting in a chair, each subject underwent measurements of PPT and ACROM (ipsilateral and contralateral side flexion and rotation, flexion and extension) preintervention, (immediately) postintervention, and at 24 h, 72 h and 7 days.

RESULTS

Superficial and deep DN produced an increase in PPT at 7 days with respect to preintervention levels. Furthermore, superficial and deep DN produced a decrease in cervical flexion at 24 h and an increase in ipsilateral rotation until 72 h, increasing to 7 days in the case of deep DN. On the contrary, superficial DN produced an increase in ipsilateral and contralateral side flexion after intervention, unlike deep DN that produced a decrease at 24 h. Furthermore, superficial DN produced an increase in contralateral rotation at 24 h and deep DN decreased extension at 72 h.

CONCLUSION

A single intervention of superficial or deep DN did not produce statistically significant changes in PPT or goniometry measurements.Trial registration number: NCT03719352 (ClinicalTrials.gov).

Effects of dry needling on gait and muscle tone in Parkinson's disease: a randomized clinical trial

BACKGROUND

Alterations in gait and muscular rigidity are common and disabling in persons with Parkinson's disease (PD).

OBJECTIVE

The aim of this study was to determine whether a single dry needling (DN) session can promote changes in gait and muscle tone in the lower extremities as well as in the evolution of the disease in persons with PD.

METHODS

A randomized double-blind clinical trial was designed. Participants were randomly assigned to an intervention group (IG) that received a session of DN over the semitendinosus, medial gastrocnemius, soleus and rectus femoris muscles, or to a control group (CG) that received a session of sham DN in the same muscles. The effects of DN were assessed using the timed up and go test (TUG), 10 meter walk test (10MWT), 6 minute walk test (6MWT) and myotonometry before, immediately after, and 7 days after the intervention.

RESULTS

Thirty-three participants were analyzed aged 69.9 ± 7.2 years (mean ± SD; 39% female). There were no significant differences between the IG and CG for any outcomes. Significant differences were observed when comparing the Pre and Follow-up values in the IG for functional mobility of gait in the TUG (p = 0.049), gait speed in the 10MWT (p = 0.041) and muscle tone in the lower extremities by myotonometry (frequency (p = 0.027) and stiffness (p = 0.013)). By comparison, there were no significant within-group differences in the CG.

CONCLUSION

A single session of DN had no measurable benefit compared to a single session of sham DN. Within-group changes in the IG suggested improvements in functional mobility of gait and gait speed, as well as changes in the muscle tone in the lower extremities of PD patients, which could be worthy of further exploration by future research.

Effects of Dry Needling of Latent Trigger Points on Viscoelastic and Muscular Contractile Properties: Preliminary Results of a Randomized Within-Participant Clinical Trial

This study aimed to evaluate changes in neuromuscular function and pain perception in latent trigger points (TrPs) in the gastrocnemius muscle after a single session of dry needling. A randomized within-participant clinical trial was conducted. Fifty volunteers with latent TrPs in the gastrocnemius muscles were explored. Each extremity was randomly assigned to a control or experimental (dry needling) group. Viscoelastic parameters and contractile properties were analyzed by tensiomyography. Ankle dorsiflexion range of motion was assessed with the lunge test. Pressure pain thresholds (PPT) and pain perceived were also analyzed. The results observed that three viscoelastic proprieties (myotonometry) showed significant differences in favor of the experimental extremity in the lateral gastrocnemius: stiffness (p = 0.02), relaxation (p = 0.045), and creep (p = 0.03), but not in the medial gastrocnemius. No changes in tensiomyography outcomes were found. The control extremity showed a higher increase in PPTs (i.e., decrease in pressure pain sensitivity) than the experimental extremity (p = 0.03). No significant effects for range of motion or strength were observed. In general, gender did not influence the effects of dry needling over latent TrPs in the gastrocnemius muscle. In conclusion, a single session of dry needling was able to change some parameters of neuromuscular function, such as muscle tone, relaxation, pressure pain sensitivity, and creep in the lateral (but not medial) gastrocnemius but did not improve strength or range of motion.

The Influence of Verbal Suggestion on Post-Needling Soreness and Pain Processing after Dry Needling Treatment: An Experimental Study

BACKGROUND

It remains unclear as to whether verbal suggestions and expectancies can influence the perception of post-needling soreness. The aim of this study was to analyze the effects of verbal suggestions on post-needling soreness after dry needling of the trapezius muscle.

METHODS

This study is a randomized controlled trial including healthy subjects randomly assigned to one of three groups receiving different verbal suggestions about the effects of dry needling and the occurrence of post needling soreness (positive, negative, or neutral). Then, dry needling on a latent trigger point of the upper trapezius muscle was performed and the following outcomes were measured immediately after, 24, 48, and 72 h, and one week after the intervention: post-needling soreness intensity, pressure pain threshold (PPT), temporal summation (TS) and conditioned pain modulation (CPM).

RESULTS

Seventy-three consecutive participants were screened and 42 participants (12 men and 30 women, aged: 24 ± 8 years old) were eligible and finished the study protocol. The results showed that verbal suggestion did not influence the perception of post-needling soreness, since there were no differences between groups (p < 0.05) on the intensity of post-needling soreness or tenderness over a one-week follow-up. Moreover, verbal suggestion did not associate with changes in sensorimotor variables of TS and CPM.

CONCLUSIONS

The induction of different types of expectations through verbal suggestion does not influence the perception of acute pain perceived during the performance of a deep dry needling technique and post-needling pain or soreness after deep dry needling on a latent upper trapezius myofascial trigger point (MTrP).

Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis

OBJECTIVE

The main objective of this systematic review and meta-analysis was to determine the short-, medium-, and long-term effectiveness of dry needling (DN) applied by physical therapists to myofascial trigger points for the treatment of pain.

METHODS

PubMed, Scopus, SportDiscus, and Web of Science databases were searched from their inception to February 2020. Randomized controlled trials that compared DN with other treatments or placebo and measured pain with a visual analog Scale or another numerical pain rating scale were included. Two authors used a personalized form to collect the following data relevant to the objectives of the review from each article independently: study design, purpose, sample size, diagnosis, characteristics of DN intervention, characteristics of placebo intervention, outcome measures, period of assessment, body region, DN technique, and number of sessions. The initial search identified 1771 articles. After the selection, 102 articles were assessed for eligibility; 42 of these articles measuring pain were used for the meta-analysis. Four meta-analyses were performed according to the follow-up period from the last reported treatment.

RESULTS

This meta-analysis found a large effect to decrease pain within 72 hours (standardized mean difference [SMD] = -0.81; 95% CI = -1.21 to -0.40), a moderate effect in 1 to 3 weeks (SMD = -0.69; 95% CI = -1.02 to -0.35), a large effect in 4 to 12 weeks (SMD = -0.85; 95% CI = -1.30 to -0.40), and a large effect in 13 to 24 weeks (SMD = -0.81; 95% CI = -1.64 to -0.03). The risk of bias was generally low; however, the heterogeneity of the results downgraded the level of evidence.

CONCLUSIONS

Low-quality evidence that the immediate to 72-hour (large) effect, 4- to 12-week (large) effect, 13- to 24-week (large) effect, and moderate-quality 1- to 3-week (moderate) effect suggested that DN performed by physical therapists was more effective than no treatment, sham DN, and other therapies for reducing pain.

IMPACT

DN is commonly used by physical therapists to treat musculoskeletal pain, and it is very important for physical therapists to know the clinical conditions and time periods for which DN is effective in reducing pain in their patients.

Effects of Deep Dry Needling on Tremor Severity and Functionality in Stroke: A Case Report

This study aimed to determine the effect of one session of dry needling on the severity of tremor, motor function and skills, and quality of life of a 39-year-old woman with post-stroke tremor. Myofascial trigger points (MTrP) of the following muscles were treated: extensor digitorum, flexor digitorum superficialis and profundus, brachioradialis, short head of biceps brachii, long head of triceps brachii, mid deltoid, infraspinatus, teres minor, upper trapezius, and supraspinatus. Outcomes were assessed via (i) clinical scales (activity of daily living (ADL-T24), a visual analog scale (VAS), and the Archimedes spiral), (ii) a functional test (9-Hole Peg test), and (iii) biomechanical and neurophysiological measurements (inertial sensors, electromyography (EMG), and dynamometry). The subject showed a decrease in the severity of tremor during postural (72.7%) and functional (54%) tasks after treatment. EMG activity decreased after the session and returned to basal levels 4 days after. There was an improvement post-intervention (27.84 s) and 4 days after (32.43 s) in functionality and manual dexterity of the affected limb, measured with the 9-Hole Peg test, as well as in the patient's hand and lateral pinch strength after the treatment (26.9% and 5%, respectively), that was maintained 4 days later (15.4% and 16.7%, respectively).

Benefits of Adding Gluteal Dry Needling to a Four-Week Physical Exercise Program in a Chronic Low Back Pain Population. A Randomized Clinical Trial

OBJECTIVE

To determine if adding dry needling to a four-week exercise program has an additional benefit compared with adding sham dry needling to the same exercise program in subjects with chronic low back pain.

DESIGN

Randomized clinical trial.

SETTING

Physiotherapy and Pain Clinic of Alcala University.

SUBJECTS

Forty-six patients with chronic low back pain.

METHODS

Subjects were randomized to two groups: the dry needling group (N = 23) or sham dry needling group (N = 23). Both groups received a four-week exercise program and before the exercise started a session of dry needling or sham dry needling. Pain (visual analog scale), disability (Roland-Morris Questionnaire), and fear avoidance beliefs (Fear Avoidance Beliefs Questionnaire) were assessed at baseline, after treatment, and at three-month follow-up. Pressure pain thresholds (algometer) were measured at baseline, after the dry needling or the sham dry needling, and after treatment.

RESULTS

Both groups showed significant improvements for all variables. In the between-group comparison, the dry needling group improved significantly in pain at three-month follow-up and pressure pain thresholds at the end of treatment for all measures, and at three-month follow-up there was no improvement in gluteus medium.

CONCLUSIONS

In chronic low back patients, adding dry needling to a four-week exercise program has an additional benefit in pain and sensitivity compared with adding sham dry needling to the same exercise program.

Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients

BACKGROUND

Stroke is the fourth leading cause of death in Europe, represents one of the most common causes of disability in adult patients, and involves considerable short- and long-term social and healthcare costs. The effectiveness of deep dry needling (DDN) on affected arm functionality was assessed throughout 8 weeks of treatment in patients with stroke in the subacute phase.

METHODS

Eighty patients were included in this two-group non-randomised study after a propensity score analysis was carried out. Both groups received standard physiotherapy treatment on the affected arm. The needling group also received six sessions of DDN during the 8-week period. Patients were evaluated before and after each session using the Fugl-Meyer upper extremity (FM UE) scale, the modified modified Ashworth scale (MMAS), the resistance to passive movement scale (REPAS) and a 10-point numeric pain rating scale (NPRS 10). The Brunnstrom recovery stage was recorded at the beginning and at the end of the study, and the EuroQoL quality of life survey was completed at the beginning of the study, after the first month of treatment and at the end of the study.

RESULTS

Patients treated with DDN showed a reduction in spasticity measured using the REPAS (p < 0.001) and the MMAS (p < 0.05). There was also an improvement in the Brunnstrom recovery stages (p < 0.05).

CONCLUSION

The addition of a specific DDN treatment to a standard physiotherapy treatment appeared to lead to a higher reduction in spasticity in the affected arm; however, it did not provide additional changes in functionality, pain and quality of life. Further studies with a randomised controlled trial design are required to confirm our findings.

Percutaneous Application of Galvanic Current in Rodents Reverses Signs of Myofascial Trigger Points

An increase in the spontaneous release of acetylcholine (ACh) at the motor endplate is directly related to the generation of myofascial trigger points (MTrPs). In this study, percutaneous electric fields were applied to an animal model of MTrPs with high levels of spontaneous ACh release. All experiments were performed on Swiss mice and Sprague Dawley rats. For evaluating the spontaneous neurotransmission, intracellular recordings were performed, and the frequency of miniature endplate potentials was evaluated. Electromyographic recordings were also conducted to evaluate the endplate noise. Finally, the number and strength of local twitch responses (LTR) were evaluated using ultrasound recordings. The protocols used for the electric currents were 0.4 mA for five seconds and four repetitions (protocol 1), 1.5 mA for five seconds and three repetitions (protocol 2), and 3 mA for three seconds and three repetitions (protocol 3). After a subcutaneous injection of neostigmine (NTG), a great increase was observed in the frequency of mEPPs, together with an elevated endplate noise. Protocols 2 and 3 were the most effective. Protocol 3 could completely reverse the action of NTG at both three hours and 24 hours, respectively. The application of percutaneous currents produced both an increase in the number (144%) and in the speed (230% faster) of LTR compared with dry needling. In conclusion, higher doses of electrical current are more effective for decreasing MTrPs findings in an animal model.

Effects of pain neuroscience education and dry needling for the management of patients with chronic myofascial neck pain: a randomized clinical trial

OBJECTIVES

The aim of this study was to observe the medium-term effects on pain, disability, and psychological factors of a combination of myofascial trigger point (MTrP) dry needling (DN) with pain neuroscience education (PNE) versus DN alone versus control care as usual (CUC) in patients with chronic neck pain.

METHODS

A total of 60 patients were randomly selected in a Spanish National Health Service Public Hospital and divided into three groups: 6 sessions of DN with 3 sessions of PNE (TrPDN + PNE group, n = 21), 6 sessions of DN alone (TrPDN group, n = 20), or 10 sessions of usual care (CUC group, n = 19). The primary outcome was neck pain intensity, while neck disability, medication intake, and psychological factors were secondary outcomes. These variables were measured at baseline, post-treatment, and at 1 month and 3 months after treatment.

RESULTS

TrPDN + PNE and DN alone were associated with greater reductions in pain intensity and disability compared to CUC (p < 0.01). TrPDN + PNE resulted in greater improvements in kinesiophobia, pain anxiety, and pain-related beliefs than DN alone and CUC (p < 0.01). No differences between groups were observed in medication intake, quality of life, catastrophizing, depression, or fear of pain (p > 0.05).

DISCUSSION

Provision of PNE and DN in the management of chronic neck pain in a Spanish National Health Service Public Hospital was associated with greater improvements in psychological factors than DN therapy only.

CONCLUSION

DN alone was more effective at reducing chronic non-specific neck pain and disability than CUC at 3-month follow-up. However, the inclusion of PNE combined with DN resulted in greater improvements in kinesiophobia, pain anxiety, and pain-related beliefs.

TRIAL REGISTRATION NUMBER

NCT03095365 (ClinicalTrials.gov).

Effects of Kinesio Taping on Post-Needling Induced Pain After Dry Needling of Active Trigger Point in Individuals With Mechanical Neck Pain

OBJECTIVE

The purpose of this study was to assess the effectiveness of the application of kinesio taping in reducing induced pain after dry needling of active trigger points (TrPs) to the upper trapezius muscle.

METHODS

Consecutive patients had mechanical neck pain (n = 34, 44% female) with active TrPs in the upper trapezius muscle. All participants received dry needling into upper trapezius active TrPs. Then, they were randomly divided into a kinesio taping group, which received an adhesive tape (Kinesio Tex), and a control group, which did not receive the taping. The numeric pain rating scale was assessed (0-10) at post-needling; immediately after; and 24 hours, 48 hours, and 72 hours after needling. Neck- and shoulder-related disability was assessed before and 72 hours after needling with the Neck Disability Index (NDI) and the Shoulder Pain and Disability Index, respectively. The pressure pain threshold (PPT) over the TrP was also assessed post-needling, immediately post-intervention, and 72 hours after needling.

RESULTS

The analysis of covariance did not find a significant group × time interaction (P = .26) for post-needling soreness: both groups exhibited similar changes in post-needling induced pain (P < .001). No significant group × time interactions were observed for changes in NDI (P = .62), SPADI (P = .41), or PPTs (P = .52): similar improvements were found after the needling procedure for the NDI (P < .001), Shoulder Pain and Disability Index (P < .001), and PPT (P < .001). The number of local twitch responses and sex (all, P > .30) did not influence the effect for any outcome.

CONCLUSION

The application of kinesio taping after dry needling of active TrPs in the upper trapezius muscle was not effective for reducing post-needling induced pain in people with mechanical neck pain. Further, the application of kinesio taping as a post-needling intervention did not influence short-term changes in disability.

The effect of dry needling on the active trigger point of upper trapezius muscle: Eliciting local twitch response on long-term clinical outcomes

BACKGROUND

Pain from myofascial trigger points is often treated by dry needling (DN). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential. Muscle damage after eliciting LTR can increase the risk of tissue fibrosis in some cases.

OBJECTIVE

This study aimed to compare two methods of DN including with and without LTR on clinical parameters.

METHODS

Twenty-six participants suffering from chronic non-specific neck pain with an active trigger point (TrP) in their upper trapezius muscles were recruited via the convenience sampling method. Participants were randomly assigned in DN with LTR (control group) and without eliciting LTR or "de qi" (experimental group). Then, they received 3 sessions of dry needling, 3 days apart. We evaluated pain, pain pressure threshold, active cervical lateral flexion range of motion, and Neck Disability Index before the intervention and 4 weeks after the treatment.

RESULTS

After the treatment, significant higher changes were seen in the experimental group compared to the control group (p< 0.05) regarding pain, pain pressure threshold, and active cervical lateral flexion. However, there was no significant difference between groups according to the disability (p> 0.05).

CONCLUSION

DN without eliciting LTR has superiority over the DN along with eliciting LTR while the treatment aimed to receive long-term effects.

Effects of Myofascial Trigger Point Release on Power and Force Production in the Lower Limb Kinetic Chain

Devereux, F, O'Rourke, B, Byrne, PJ, Byrne, D, and Kinsella, S. Effects of myofascial trigger point release on power and force production in the lower limb kinetic chain. J Strength Cond Res 33(9): 2453-2463, 2019-The purpose of this study was to first investigate the effects of treating latent myofascial trigger points (MTrPs) in the lower limb kinetic chain with respect to performance during sporting actions, as opposed to the traditional goal of pain management with active MTrPs. The second aim was to investigate the effects of dry needling (DN) on performance parameters over time to establish treatment timeframe guidelines before performance. Forty male athletes were assigned to 4 groups; rectus femoris DN (group 1), medial gastrocnemius DN (group 2), rectus femoris and medial gastrocnemius DN (group 3), and no DN (group 4). Subjects completed 6 sessions; familiarization, baseline, immediately after DN, 48, 72, and 96 hours after intervention. Subjects performed squat jumps at 5 incremental loads and were recorded using the My Jump app (iOS) for jump height, power output, optimal force, and optimal velocity. A between-within subject's analysis of variance was used for statistical analysis. Results showed a significant increase in jump height in group 2 (gastrocnemius muscle only) from immediately after to 48 hours after intervention (p = 0.01); however, no other statistical significance was observed. From 48 hours onward, a trend for improved performance was observed, with jump height, power, and velocity showing trivial increases. This study found improved jump performance from immediately after to 48 hours post-DN of the gastrocnemius muscle only. This study suggests a likely immediate decrease in jump performance after DN, with levels increasing above baseline between 48 and 96 hours, which may have clinical significance.

Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: A randomized controlled trial

BACKGROUND

Dry needling (DN) in active myofascial trigger points (MTrPs) is effective to reduce pain, increase range of motion (ROM) and improve physical function in different musculoskeletal disorders. However, there is a lack of studies evaluating the effects of DN in active MTrPs in hip osteoarthritis (OA).

OBJECTIVE

To determine the short-term effects of DN on pain, hip ROM and physical function in patients with hip OA.

DESIGN

Double-blind randomized controlled trial.

METHODS

Thirty patients with unilateral hip OA were randomized into two groups: DN group and sham group. Participants received three treatment sessions. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus muscles. Pain intensity (visual analogic scale), passive hip ROM (universal goniometer and digital inclinometer) and physical function (30s chair-stand test and 20m walk test) were assessed at baseline and after the three treatment sessions.

RESULTS

There was decreased pain intensity, increased hip ROM, and improved physical function following the DN treatment. These improvements were statistically significant (p < 0.05) compared to the sham group. The sham group had increased pain intensity and decreased hip ROM (p < 0.05).

CONCLUSION

Pain, hip ROM, and physical function improved after the application of DN in active MTrPs of the hip muscles in patients with hip OA.

Trigger point dry needling for the treatment of myofascial pain syndrome: current perspectives within a pain neuroscience paradigm

Myofascial pain syndrome is a pain condition characterized by the presence of trigger points. Current evidence, mostly experimental studies, clearly supports a role of trigger points on peripheral and central sensitization since they are able to contribute to sensitization of peripheral nociceptors, spinal dorsal horn neurons, and the brainstem. Several interventions are proposed for treating trigger points, dry needling being one of the most commonly used by clinicians. There is no consensus on the clinical application of trigger point dry needling: some authors propose that local twitch responses should be elicited during the needling intervention to be effective, whereas others do not. The application of trigger point dry needling is able to reduce the excitability of the central nervous system by reducing peripheral nociception associated to the trigger point, by reducing dorsal horn neuron activity, and by modulating pain-related brainstem areas. However, the effects are mainly observed in the short-term, and effect sizes are moderateto small. Therefore, the current review proposes that the application of trigger point dry needling should be integrated into current pain neuroscience paradigm by combining its application with pain neuroscience education, graded exercise and manual therapy. Additionally, patient’s expectations, beliefs, previous experiences and patient–clinician interaction should be considered when integrating trigger point dry needling into a comprehensive treatment approach.

Localization of Muscle Edema and Changes on Muscle Contractility After Dry Needling of Latent Trigger Points in the Gastrocnemius Muscle

In this article, we aimed to describe what happens in skeletal muscle after dry needling intervention using magnetic resonance imaging (to show if there is edema) and tensiomyography (to measure contractile properties). At the same time, we describe the relationship between pain, edema, and contractility. Our results suggest that in asymptomatic patients, the application of dry needling over latent trigger points produce intra-muscular edema, an increase in muscle stiffness and an improved muscle contraction time.

Dry Needling on the Infraspinatus Latent and Active Myofascial Trigger Points in Older Adults With Nonspecific Shoulder Pain: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Shoulder pain is a prevalent condition in older adults. Some authors associate nonspecific shoulder pain with myofascial trigger points (MTrPs) in the infraspinatus muscle. Dry needling is recommended to relieve the MTrP pain of shoulders in the short term (<9 days). Active MTrPs dry needling improves shoulder pain and the irritability of the satellite MTrPs in the referred pain area. Nociceptive activity at a latent MTrP may influence motor activity and the sensitivity of MTrPs in distant muscles at a similar segmental level. Therefore, this study aimed to evaluate dry needling on 1 latent MTrP, in conjunction with 1 active MTrP, in the infraspinatus muscle of older adults with nonspecific shoulder pain.

METHODS

A single-center, randomized, single-blinded, controlled study (NCT02032602) was carried out. Sixty-six patients aged 65 years and older with trigger points in the ipsilateral infraspinatus of the painful shoulder were randomly assigned to (1) of (2) treatment groups. A session of dry needling on the infraspinatus was performed in (1) the most hyperalgesic active and latent MTrP or (2) only the most hyperalgesic active MTrP. The Numeric Rating Scale, the pressure pain threshold (primary outcome) on the anterior deltoid and extensor carpi radialis brevis latent MTrPs, and grip strength were assessed before, after, and 1 week after the intervention.

RESULTS

Statistically significant differences in the reduction of pain intensity (P ≤ .001; η = 0.159-0.269; d = 1.017-1.219) and the increase of pressure pain threshold (P < .001; η = 0.206-0.481; d = 0.870-1.924) were found for the (1) treatment group immediately and 1 week postintervention. Nevertheless, no statistical significant differences were found in grip strength (P >. 05; η = 0.006-0.033; d = 0.158-0.368).

CONCLUSIONS

One dry needling intervention of the latent MTrP associated with the key active MTrP of the infraspinatus reduces pain intensity and the irritability of the satellite MTrPs located in the referred pain area in the short term in older adults with nonspecific shoulder pain.

Postneedling Soreness and Tenderness After Different Dosages of Dry Needling of an Active Myofascial Trigger Point in Patients With Neck Pain: A Randomized Controlled Trial

BACKGROUND

Previous studies in asymptomatic subjects have demonstrated that myofascial trigger point (MTrP) dry needling frequently is associated with postneedling soreness. However, to the authors' knowledge, there is not any study that performs a detailed description of postneedling soreness characteristics in patients with myofascial pain. This information could help clinicians to make evidence-informed decisions considering the benefits and negative effects of different dry needling dosages.

OBJECTIVE

To (1) compare the prevalence, intensity, and duration of postneedling soreness and tenderness after different dosages of deep dry needling (DDN) and (2) analyze the influence on postneedling soreness of psychological factors and other factors involved in the DDN process DESIGN: 1-week follow-up, double-blind randomized controlled trial.

SETTING

University community.

PARTICIPANTS

Patients (n = 120: 34 male; 86 female) aged 18-53 years (median ± interquartile range, 21.0 ± 7.0 years) with active MTrPs in the upper trapezius.

INTERVENTION

All patients received DDN in an active MTrP. They were randomly divided into 4 groups: no local twitch responses (LTRs) elicited (control group), 4 LTRs elicited, 6 LTRs elicited, and DDN until no more LTRs were elicited.

MAIN OUTCOME MEASURES

Postneedling soreness and pressure pain threshold were assessed before treatment, during DDN procedure, and every 24 hours during 1 week.

RESULTS

Postneedling soreness showed a significant effect for time (F_2,006 = 173.603; P < .001, η_p² = 0.659) and a significant interaction between group and time (F_6,017 = 3.763; P = .001; η_p² = 0.111). Pressure pain threshold showed a significant effect for time (F_2,377 = 16.833; P < .001; η_p² = 0.127) and a significant interaction between group and time (F_7,130 = 2.100; P = .04; η_p² = 0.052). Psychological factors did not show relevant correlations with the intensity of postneedling soreness.

CONCLUSIONS

Postneedling soreness is present in most of subjects after DDN of active MTrPs. The groups in which DDN was performed eliciting LTRs exhibited greater post-needling soreness. The number of needle insertions was associated with postneedling soreness but psychological factors did not seem to play a relevant role on its perception.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02190890 LEVEL OF EVIDENCE: I.

Post-needling soreness after myofascial trigger point dry needling: Current status and future research

Post-dry needling soreness is a common complication of myofascial trigger point (MTrP) dry needling treatment. The prevention, management and relevance of this complication remain uncertain. This paper examines the current state of knowledge and suggests directions for further studies in this area. MTrPs are hypersensitive nodules in skeletal muscles' taut bands, present in several pain conditions. Dry needling has been recommended for relieving MTrP pain. MTrP dry needling procedures have shown to be associated with post-needling soreness, which is thought to be a consequence of the neuromuscular damage, and hemorrhagic and inflammatory reaction generated by the needle. Postneedling soreness is a very frequent effect after deep dry needling, usually lasting less than 72 h. It may not be especially distressing for most patients. However, patients presenting with higher levels of post-needling soreness, not perceiving dry needling effectiveness in the first session, or not having high myofascial pain intensity before treatment, could be the most likely to find post-needling soreness more distressing, functionally limiting and to abandon treatment. Future research should assess the clinical relevance of post-needling soreness. Post-needling soreness should be considered when investigating dry needling effectiveness since it could overlie the original myofascial pain and influence the patients' pain ratings.

A Multimodal Approach for Myofascial Pain Syndrome: A Prospective Study

OBJECTIVE

The purpose of this study was to analyze pain intensity in patients with myofascial pain syndrome (MPS) following a multimodal rehabilitation protocol.

METHODS

A prospective study was carried out following the Template for Intervention Description and Replication criteria. Patients were recruited from the rehabilitation unit of a university hospital in Spain between 2009 and 2013. Patients were included if they had a medical diagnosis of MPS in any of the following regions: cervicobrachial (n = 102), lumbosacral (n = 30), elbow (n = 14), ankle and foot (n = 10), and temporomandibular jaw (n = 1). The multimodal rehabilitation protocol included myofascial trigger point dry needling, spray and stretching, Kinesio taping, eccentric exercise, and patient education. The protocol was applied for 4 weeks (5 sessions) for the active and/or latent myofascial trigger points in each body region. Pain intensity was measured by using the visual analog scale (VAS) immediately before beginning of the study and 1 week after completion of the protocol.

RESULTS

The study sample comprised 150 patients (mean ± standard deviation age, 51.5 ± 1.19 years). Statistically significant differences were obtained for reduction in pain intensity (4 ± 2.03; P = .002). Clinically relevant reductions (VAS ≥30 mm; P < .001) were obtained in 78.7% of the interventions. Four treatment sessions reduced the VAS score by 10 mm in 83.55% of the sample. There were no statistically significant differences (P = .064) for reduction in pain intensity in the different body regions.

CONCLUSIONS

A multimodal rehabilitation protocol showed clinically relevant differences in the reduction in pain intensity in different body regions in patients with MPS.

Impact of Needle Diameter on Long-Term Dry Needling Treatment of Chronic Lumbar Myofascial Pain Syndrome

Supplemental digital content is available in the text.

Objective

To investigate the impact of diameter of needles on the effect of dry needling treatment of chronic lumbar myofascial pain syndrome.

Design

Forty-eight patients with chronic lumbar myofascial pain syndrome were randomly allocated to 3 groups. They received dry needling with needles of diameter 0.25 (group A), 0.5 (group B), and 0.9 mm (group C). Visual analog scale evaluation and health survey were conducted at baseline and 3 months after the treatment.

Results

Visual analog scale scores were significantly different in all groups from baseline to 3 months. Visual analog scale scores at 3 months showed differences between group C and the other 2 groups. When baseline and 3 months after treatment (0 day and 3 months) in each of the 3 groups was compared, there was a difference between group C and group B. The Short Form (36) Health Survey scores from baseline to 3 months were different within the treatment groups.

Conclusions

Visual analog scale score evaluations at 3 months showed efficacy in all groups. Results of 3 months showed that efficacy of treatment with larger needles (0.9-mm diameter) was better than that of smaller ones (0.5-mm diameter). The Short Form (36) Health Survey scores at 3 months indicated that treatments with needles of varying diameters were all effective, and when the results of 3 months were compared, there was no difference between the 3 groups.

Effects of Low-Load Exercise on Postneedling-Induced Pain After Dry Needling of Active Trigger Point in Individuals With Subacromial Pain Syndrome

BACKGROUND

The application of dry needling usually is associated with postneedling-induced pain. A postneedling intervention to reduce this adverse event is needed.

OBJECTIVE

To determine the effectiveness of low-load exercise on reducing postneedling-induced pain after dry needling of active trigger points (TrPs) in the infraspinatus muscle in subacromial pain syndrome.

DESIGN

A 72-hour follow-up, single-blind randomized controlled trial.

SETTING

Urban hospitals.

PARTICIPANTS

Individuals with subacromial pain syndrome (n = 90, 52% female, mean age: 35 ± 13 years) with active TrPs in the infraspinatus muscle.

INTERVENTIONS

All individuals received dry needling into the infraspinatus active TrP. Then, they were divided randomly into an experimental group, which received a single bout of low-load exercise of shoulder muscles; a placebo group, which received inactive ultrasound for 10 minutes; and a control group, which did not receive any intervention.

OUTCOME MEASURES

Numerical Pain Rating Scale (0-10 point) was administered postneedling, immediately postintervention (2 minutes), and 24, 48, and 72 hours after needling. Shoulder pain (Numerical Pain Rating Scale, 0-10) and disability (Disabilities of the Arm, Shoulder and Hand; Shoulder Pain and Disability Index) were assessed before and 72 hour after needling.

RESULTS

The 5 × 3 analysis of covariance showed that the exercise group demonstrated a larger decrease in postneedling-induced pain immediately after (P = .001), 24 hours (P = .001), and 48 hours after (P = .006) than placebo or control groups. No differences were found at 72 hours (P = .03). Similar improvements in shoulder pain (P < .001) and related disability (Disabilities of the Arm, Shoulder and Hand: P < .001; Shoulder Pain and Disability Index: P < .001) were observed 72 hours after needling, irrespective of the treatment group.

CONCLUSIONS

Low-load exercise was effective for reducing postneedling-induced pain on active TrPs in the infraspinatus muscle 24 and 48 hours after needling. The application of a postneedling intervention did not influence short-term pain and disability changes.

LEVEL OF EVIDENCE

I.

Efficacy of quadriceps vastus medialis dry needling in a rehabilitation protocol after surgical reconstruction of complete anterior cruciate ligament rupture

BACKGROUND

Several new rehabilitation modalities have been proposed after anterior cruciate ligament (ACL) reconstruction. Among these, trigger point dry needling (TrP-DN) might be useful in the treatment of myofascial pain syndrome associated with ACL reconstruction to reduce pain intensity, increase knee flexion range and modify the mechanical properties of the quadriceps muscle during late-stage rehabilitation. To date, this is the first randomized clinical trial to support the use of TrP-DN in the early rehabilitation process after ACL reconstruction. The aim of this study was to determine the pain intensity, range of motion (ROM), stability, and functionality improvements by adding quadriceps vastus medialis TrP-DN to the rehabilitation protocol (Rh) provided to subacute ACL reconstructed patients.

METHODS

This randomized, single-blinded, clinical trial (NCT02699411) included 44 subacute patients with surgical reconstruction of complete ACL rupture. The patients were randomized into 2 intervention groups: Rh (n = 22) or Rh + TrP-DN (n = 22). Pain intensity, ROM, stability, and functionality were measured at baseline (A0) and immediately (A1), 24 hours (A2), 1 week (A3), and 5 weeks (A4) after the first treatment.

RESULTS

Comparing statistically significant differences (P ≤ .001; Eta = 0.198-0.360) between both groups, pain intensity (at A1), ROM (at A1, A2, and A3), and functionality (at A2, A3, and A4) were increased. Nevertheless, the rest of measurements did not show significant differences (P > .05).

CONCLUSION

Quadriceps vastus medialis TrP-DN in conjunction with a rehabilitation protocol in subacute patients with surgical reconstruction of complete ACL rupture increases ROM (short-term) and functionality (short- to mid-term). Although there was an increase in pain intensity with the addition of TrP-DN, this was not detected beyond immediately after the first treatment. Furthermore, stability does not seem to be modified after TrP-DN.

The local twitch response during trigger point dry needling: Is it necessary for successful outcomes?

BACKGROUND

Myofascial trigger point (MTrP) injection and trigger point dry needling (TrPDN) are widely accepted therapies for myofascial pain syndrome (MPS). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential.

OBJECTIVE

This is the first review exploring the available literature, regardless of study design, on the neurophysiological effects and clinical significance of the LTR as it relates to reductions in pain and disability secondary to MTrP needling.

METHODS

PubMed, MEDLINE, Science Direct and Google Scholar were searched up until October 2016 using terms related to trigger point needling and the LTR.

RESULTS

and Discussion: Several studies show that eliciting a LTR does not correlate with changes in pain and disability, and multiple systematic reviews have failed to conclude whether the LTR is relevant to the outcome of TrPDN. Post needling soreness is consistently reported in studies using repeated in and out needling to elicit LTRs and increases in proportion to the number of needle insertions. In contrast, needle winding without LTRs to MTrPs and connective tissue is well supported in the literature, as it is linked to anti-nociception and factors related to tissue repair and remodeling. Additionally, the positive biochemical changes in the MTrP after needling may simply be a wash out effect related to local vasodilation. While the LTR during TrPDN appears unnecessary for managing myofascial pain and unrelated to many of the positive effects of TrPDN, further investigation is required.

Effectiveness of dry needling for chronic nonspecific neck pain: a randomized, single-blinded, clinical trial

Chronic neck pain attributed to a myofascial pain syndrome is characterized by the presence of muscle contractures referred to as myofascial trigger points. In this randomized, parallel-group, blinded, controlled clinical trial, we examined the effectiveness of deep dry needling (DDN) of myofascial trigger points in people with chronic nonspecific neck pain. The study was conducted at a public Primary Health Care Centre in Madrid, Spain, from January 2010 to December 2014. A total of 130 participants with nonspecific neck pain presenting with active myofascial trigger points in their cervical muscles were included. These participants were randomly allocated to receive: DDN plus stretching (n = 65) or stretching only (control group [n = 65]). Four sessions of treatment were applied over 2 weeks with a 6-month follow-up after treatment. Pain intensity, mechanical hyperalgesia, neck active range of motion, neck muscle strength, and perceived neck disability were measured at baseline, after 2 sessions of intervention, after the intervention period, and 15, 30, 90, and 180 days after the intervention. Significant and clinically relevant differences were found in favour of dry needling in all the outcomes (all P < 0.001) at both short and long follow-ups. Deep dry needling and passive stretching is more effective than passive stretching alone in people with nonspecific neck pain. The results support the use of DDN in the management of myofascial pain syndrome in people with chronic nonspecific neck pain.

Dry Needling Combined With Physical Therapy in Patients With Chronic Postsurgical Pain Following Total Knee Arthroplasty: A Case Series

Study Design Case series. Background This case series describes a combined program of dry needling and therapeutic exercise in a small group of patients with persistent pain following total knee arthroplasty (TKA). Case Description Fourteen patients who underwent TKA had persistent postsurgical pain and myofascial trigger points that were nonresponsive to treatment with conventional physical therapy and/or medication. The patients received a weekly dry needling treatment in combination with therapeutic exercises for 4 weeks. Pain perception was assessed preintervention and postintervention with a visual analog scale and function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index, 6-minute walk test, timed up-and-go test, 30-second chair-stand test, and knee joint range of motion. Outcomes After TKA, the patients had a mean ± SD symptom duration of 6.3 ± 3.1 months. Subsequent to dry needling, patients reported a significant mean ± SD decrease in pain intensity from 55.6 ± 6.6 to 19.3 ± 5.6 (P<.001) and improvements in Western Ontario and McMaster Universities Osteoarthritis Index scores from 10.1 ± 0.8 to 4.9 ± 1.0 for pain (P<.001), from 5.3 ± 0.4 to 2.4 ± 1.2 for stiffness (P<.001), and from 36.7 ± 2.0 to 20.1 ± 3.2 for function (P<.001). Knee flexion increased from a mean ± SD of 82.7° ± 5.2° to 93.3° ± 4.3° (P<.001), and joint extension improved from 15.8° ± 2.9° to 5.3° ± 2.4° (P<.05). The 6-minute walk test also showed improvement in postintervention values from a mean ± SD of 391.4 ± 23.7 to 424.7 ± 28.4 m (P<.05). Discussion After dry needling combined with therapeutic exercises, patients who had chronic pain following TKA showed clinically significant improvements in pain, range of motion, function, and myofascial trigger points. Future randomized clinical trials should further investigate the effectiveness of this protocol under similar conditions. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2017;47(3):209-216. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7089.

Contribution of Dry Needling to Individualized Physical Therapy Treatment of Shoulder Pain: A Randomized Clinical Trial

Study Design Multicenter, parallel randomized clinical trial. Background Myofascial trigger points (MTrPs) are implicated in shoulder pain and functional limitations. An intervention intended to treat MTrPs is dry needling. Objectives To investigate the effectiveness of dry needling in addition to evidence-based personalized physical therapy treatment in the treatment of shoulder pain. Methods One hundred twenty patients with nonspecific shoulder pain were randomly allocated into 2 parallel groups: (1) personalized, evidencebased physical therapy treatment; and (2) trigger point dry needling in addition to personalized, evidence-based physical therapy treatment. Patients were assessed at baseline, posttreatment, and 3-month follow-up. The primary outcome measure was pain assessed by a visual analog scale at 3 months, and secondary variables were joint range-of-motion limitations, Constant-Murley score for pain and function, and number of active MTrPs. Clinical efficacy was assessed using intention-to-treat analysis. Results Of the 120 enrolled patients, 63 were randomly assigned to the control group and 57 to the intervention group. There were no significant differences in outcome between the 2 treatment groups. Both groups showed improvement over time. Conclusion Dry needling did not offer benefits in addition to personalized, evidencebased physical therapy treatment for patients with nonspecific shoulder pain. Level of Evidence Therapy, level 1b. Registered February 11, 2009 at www.isrctn.com (ISRCTN30907460). J Orthop Sports Phys Ther 2017;47(1):11-20. Epub 9 Dec 2016. doi:10.2519/jospt.2017.6698.

Dry needling of the trapezius muscle in office workers with neck pain: a randomized clinical trial

BACKGROUND

Neck pain is a frequent complaint in office workers. This pain can be caused by myofascial trigger points (MTrPs) in the trapezius muscle. This study aimed to determine the effectiveness of deep dry needling (DDN) of active MTrPs in the trapezius muscle.

METHODS

A randomized, single blinded clinical trial was carried out at the Physical Therapy Department at Physiotherapy in Women's Health Research Group at Physical Therapy Department of University of Alcalá, in Alcalá de Henares, Madrid, Spain. Forty-four office workers with neck pain and active MTrPs in the trapezius muscle were randomly allocated to either the DDN or the control group (CG). The participants in the DDN group were treated with DDN of all MTrPs found in the trapezius muscle. They also received passive stretch of the trapezius muscle. The CG received the same passive stretch of the trapezius muscle only. The primary outcome measure was subjective pain intensity, measured using a visual analogue scale (VAS). Secondary outcomes were pressure pain threshold (PPT), cervical range of motion (CROM) and muscle strength. Data were collected at baseline, after interventions and 15 days after the last treatment.

RESULTS

Differences were found between the DDN group and the CG for the VAS (P < 0.001), PPT (P < 0.001), range of motion (AROM) (P < 0.05) and strength (P < 0.05) after intervention and at the 15-day follow-up.

DISCUSSION

Deep dry needling and passive stretch seems to be more effective than passive stretch only. The effects are maintained in the short term. The results support the use of DDN in the management of trapezius muscle myofascial pain syndrome in neck pain.