Effects of dry needling on post-stroke brain activity and muscle spasticity of the upper limb: a case report

Effects of dry needling session frequency on wrist flexor spasticity and motor recovery after stroke: a single-blind randomized clinical trial

BACKGROUND

Determining the optimal number of dry needling (DN) sessions to satisfactorily treat a stroke patient with spasticity is important from both clinical and economic perspective.

OBJECTIVE

To explore the effects of one versus three sessions of DN on spasticity of the wrist flexors and motor recovery after stroke.

METHODS

In this single-blind randomized clinical trial, 24 patients were randomly and equally divided into two groups: one group received one session of DN, while the other group received three sessions of DN in one week. Both groups received one minute of DN of the flexor carpi radialis and flexor carpi ulnaris. The outcome measures were the Modified Modified Ashworth Scale (MMAS), passive resistance torque (PRT), wrist active and passive extension range of motion (ROM), and the Brunnstrom Stages of Stroke Recovery (BSSR) measured before, immediately after, and one week after the last DN session.

RESULTS

Both groups demonstrated a significant improvement in all outcomes (p < .05). The MMAS scores in both groups meaningfully improved (p < .001). No significant differences were found between the two groups; however, a significant time-by-group interaction was observed for the PRT (p = .02; Cohen's d = 0.23-0.73), wrist active extension ROM (p = .001; Cohen's d = 0.37-0.67), and wrist passive extension ROM (p = .02; Cohen's d = 0.32-1.30). The BSSR significantly improved from 3 to 4 in both groups (p < .001).

CONCLUSION

Administering three sessions of DN can effectively improve spasticity and motor function after stroke.

Effects of Dry Needling on Gastrocnemius Muscle Spasticity and Gait in Patients with Multiple Sclerosis: A Pilot Randomized Controlled Trial

Objective

Spasticity is a common complication in patients with multiple sclerosis (pwMS). The present study aimed to evaluate the clinical, biomechanical, and functional effects of dry needling (DN) in treating gastrocnemius muscle spasticity in pwMS.

Materials and Methods

A pilot single-blinded randomized controlled trial was carried out. Eleven patients were randomly allocated to the DN group, and 10 to the waiting list control group. A single session of DN for 2 minutes was performed for the gastrocnemius muscle. Primary outcome measures were the modified Modified Ashworth Scale (MMAS), the passive resistive torque (PRT), and the foot pressure distribution of podography. The secondary outcome measures were the active and passive ankle dorsiflexion range of motion (ROM) and timed up-and-go (TUG) test. Outcomes were measured at baseline, immediately after the intervention, and at one-week follow-up.

Results

Twenty-one pwMS with a mean age of 39.52 ± 7.24 years and MS duration of 166.86 ± 5.66 months participated in the study. There were no significant changes in all outcomes for pwMS in the control group. In the DN group, the median gastrocnemius MMAS spasticity significantly decreased after the intervention, and the improvement remained at 1-week follow-up (median decrease from "3" to "2", p = 0.004). The analysis of covariance between-group analysis showed that the PRT (effect size = 0.65) and ankle active (effect size = 0.62) and passive ROM (effect size = 0.8) improved significantly after DN. There were no significant improvements in contact area, but small effect sizes were observed for the maximum plantar force (0.28) and maximum peak pressure at follow-up. The effect size for the TUG test was moderate (0.49).

Conclusions

These findings show that a single session of DN applied for 2 min was effective in improving gastrocnemius spasticity, PRT, active and passive ankle ROM, and dynamic balance, but walking did not improve meaningfully.

Changes in Corticospinal Tract Consistency after Dry Needling in a Stroke Patient

Background

Dry needling (DN) is a technique employed to mitigate spasticity and enhance functionality in stroke patients. We report the impact of DN on both corticospinal tract (CST) consistency and wrist flexors spasticity of an individual affected by stroke.

Case

The participant was a 57-year-old male who had experienced an ischemic stroke 9 months prior. The primary outcome measures included fractional anisotropy (FA), asymmetry FA (aFA), ratio FA (rFA), and Modified Modified Ashworth Scale (MMAS). Additionally, secondary outcomes encompassed wrist extension range of motion (ROM) and performance in the box and block test (BBT). These measurements were taken both before and after the administration of DN treatment.

Results

After the application of DN, the mean FA of the ipsilesional CST increased from 0.35 to 0.39, concomitantly with a decline in aFA from 0.18 to 0.13. Notably, the rFA exhibited a pre-DN value of 0.69, which subsequently rose to 0.76 post-DN. Moreover, a significant reduction in MMAS scores was detected, from a score of "3" prior to DN application to a post-DN score of "1". In terms of wrist mobility, both active and passive extension ROM exhibited favorable improvements, with an increase of 12° for active extension and 16° for passive extension. Furthermore, there was a substantial improvement in the BBT score, an indicator of manual dexterity, ascending from 12 to 24.

Conclusion

Enhancements in CST consistency suggest it as a potential mechanism contributing to the observed improvements following DN in this stroke case.

The Effect of Ankle Muscles Dry Needling on Brain Activity Map Based on fMRI: a Study Protocol for Randomized Controlled Trial

Importance

Neuromodulation may be one of the underlying mechanisms of dry needling (DN); however, the mechanism has not yet been fully clarified.

Objective

This randomized controlled trial is designed to evaluate DN stimulation of the tibialis anterior and peroneus longus muscles in chronic ankle instability (CAI) and healthy subjects, employing functional magnetic resonance imaging (fMRI).

Design

Clinical study protocol, SPIRIT compliant.

Setting

Brain Mapping Laboratory.

Population

A total of thirty participants aged between 18 and 40 years old will be included in this study. Twenty healthy participants will be randomized into 2 groups (real DN and sham DN). Ten patients with CAI will also be recruited to the third group and receive only real DN for comparison.

Exposures

Real and sham DN.

Main Outcomes and Measures

The voxel count, coordinates of peak activation, and peak intensity will be obtained as primary outcomes to report brain map activation. Measurements will be taken before, during, and after DN treatment. The strength of the ankle dorsiflexors, active dorsiflexion range of motion, and McGill pain questionnaire short-form will be used as secondary outcome measures.

Results

The results from this study will be published in peer-reviewed journals and disseminated as presentations at national and international congresses.

Conclusion

This trial will explore brain responses to real and sham DN in healthy participants and to real DN in CAI patients. Overall, our results will provide preliminary evidence of the neural mechanism of DN.

Safety of dry needling in stroke patients: a scoping review

INTRODUCTION

Spasticity is a common problem in stroke patients. Treatments of spasticity often have side effects or are insufficiently effective. Dry needling (DN) has been proposed as a potential additional option to consider in the multimodal treatment of post-stroke spasticity, although questions about its safety remain. The goal of this study is to assess the safety of DN in stroke patients.

EVIDENCE ACQUISITION

A systematic search in Medline, Embase, The Cochrane Library, Web of Science, CIHNAL and PEDro was conducted in June 2023. Two reviewers independently screened abstracts according to the eligibility criteria.

EVIDENCE SYNTHESIS

Twenty-five articles were included in this review. Only six studies reported adverse events, all of which were considered minor. None of the included studies reported any serious adverse events. In four of the included studies anticoagulants were regarded as contra-indicative for DN. Anticoagulants were not mentioned in the other included studies.

CONCLUSIONS

There is a paucity of literature concerning the safety of DN in stroke patients. This review is the first to investigate the safety of DN in stroke patients and based on the results there is insufficient evidence regarding the safety of DN in stroke patients.

CLINICAL REHABILITATION IMPACT

Although DN could be a promising treatment in post-stroke spasticity, further research is indicated to investigate its mechanism of action and its effect on outcome. However, before conducting large clinical trials to assess outcome parameters, the safety of DN in stroke patients must be further investigated.

Effects of dry needling on spasticity, cortical excitability, and range of motion in a patient with multiple sclerosis: a case report

BACKGROUND

Dry needling is an intervention used by physiotherapists to manage muscle spasticity. We report the effects of three sessions of dry needling on ankle plantar flexor muscle spasticity and cortical excitability in a patient with multiple sclerosis.

CASE PRESENTATION

The patient was a 40-year-old Iranian woman with an 11-year history of multiple sclerosis. The study outcomes were measured by the modified modified Ashworth scale, transcranial magnetic stimulation parameters, and active and passive ankle range of motion. They were assessed before (T0), after three sessions of dry needling (T1), and at 2-week follow-up (T2). Our result showed: the modified modified Ashworth scale was improved at T2 from, 2 to 1. The resting motor threshold decreased from 63 to 61 and 57 at T1 and T2, respectively. The single test motor evokes potential increased from 76.2 to 78.3. The short intracortical inhibition increased from 23.6 to 35.4 at T2. The intracortical facilitation increased from 52 to 76 at T2. The ankle active and passive dorsiflexion ROM increased ~ 10° and ~ 6° at T2, respectively.

CONCLUSION

This case study presented a patient with multiple sclerosis who underwent dry needling of ankle plantar flexors with severe spasticity, and highlighted the successful use of dry needling in the management of spasticity, ankle dorsiflexion, and cortical excitability. Further rigorous investigations are warranted, employing randomized controlled trials with a sufficient sample of patients with multiple sclerosis. Trial registration IRCT20230206057343N1, registered 9 February 2023, https://en.irct.ir/trial/68454.

Effects of neurorehabilitation with and without dry needling technique on muscle thickness, reflex torque, spasticity and functional performance in chronic ischemic stroke patients with spastic upper extremity muscles: a blinded randomized sham-controlled clinical trial

PURPOSE

Evaluation the effects of dry needling on sonographic, biomechanical and functional parameters of spastic upper extremity muscles.

METHODS

Twenty-four patients (35-65 years) with spastic hand were randomly allocated into two equal groups: intervention and sham-controlled groups. The treatment protocol was 12-sessions neurorehabilitation for both groups and 4-sessions dry needling or sham-needling for the intervention group and sham-controlled group respectively on wrist and fingers flexor muscles. The outcomes were muscle thickness, spasticity, upper extremity motor function, hand dexterity and reflex torque which were assessed before, after the 12th session, and after one-month follow-up by a blinded assessor.

RESULTS

The analysis showed that there was a significant reduction in muscle thickness, spasticity and reflex torque and a significant increment in motor function and dexterity in both groups after treatment (p < 0.01). However, these changes were significantly higher in the intervention group (p < 0.01) except for spasticity. Moreover, a significant improvement was seen in all outcomes measured one-month after the end of the treatment in the intervention group (p < 0.01).

CONCLUSIONS

Dry needling plus neurorehabilitation could decrease muscle thickness, spasticity and reflex torque and improve upper-extremity motor performance and dexterity in chronic stroke patients. These changes were lasted one-month after treatment.Trial Registration Number: IRCT20200904048609N1IMPLICATION FOR REHABILITATIONUpper extremity spasticity is one of the stroke consequences which interfere with motor function and dexterity of patient hand in activity of daily livingApplying the dry needling accompanied with neurorehabilitation program in post-stroke patients with muscle spasticity can reduce the muscle thickness, spasticity and reflex torque and improve upper extremity functions.

Dry needling combined with exercise therapy: Effects on wrist flexors spasticity in post-stroke patients - A randomized controlled trial

BACKGROUND

The positive contribution of dry needling (DN) in conjunction with exercise therapy for patients with stroke and spasticity remains uncertain.

OBJECTIVE

To examine the effects of DN combined with exercise therapy on wrist flexor spasticity and motor function in patients with stroke.

METHODS

Twenty-four participants with stroke were randomly assigned to either the DN and exercise therapy group or the DN alone group. Assessments were conducted at baseline, after the 4th treatment session, and 3 weeks post-treatment.

RESULTS

A significant Group×Time interaction was observed for wrist active range of motion (ROM) (P = 0.046), favoring the DN with exercise therapy group (∼10° at baseline, ∼15° immediately after the 4th session, and 15.4° at follow-up). The improvements in spasticity, passive ROM, and H-reflex latency were sustained during follow-up. However, there were no significant between-group differences in any outcome at any measurement time point.

CONCLUSION

The combined DN and exercise therapy did not exhibit superiority over DN alone concerning spasticity severity and motor function. However, it demonstrated additional advantages, particularly in improving motor neuron excitability and wrist passive extension.

The Effectiveness of a Single Dry Needling Session on Gait and Quality of Life in Multiple Sclerosis: A Double-Blind Randomized Sham-Controlled Pilot Trial

INTRODUCTION

Gait disorders are a major cause of disability and reduced health-related quality of life in people with multiple sclerosis (pwMS). Dry needling (DN) has demonstrated positive results to improve gait parameters in patients with stroke. The main aim of this study was to evaluate the effect of a single session of DN in the gait performance of pwMS.

METHODS

A double-blind parallel randomized sham-controlled pilot trial was conducted. Study participants received a single session of active DN or sham DN in the gastrocnemius medialis muscle. Pre-treatment and immediately post-treatment measurements were taken, as well as at one and four weeks after the intervention. Outcomes related to gait performance (Timed 25-Foot Walk), self-perceived walking capacity (Multiple Sclerosis Walking Scale), risk of falls (Timed Up and Go test), disability level (Expanded Disability Status Score) and quality of life (Multiple Sclerosis Quality of Life-54 questionnaire and Analogic Quality of Life scale) were evaluated.

RESULTS

18 patients who had multiple sclerosis participated in the study. The group who received active DN showed within-group significant statistical differences immediately after treatment for gait performance (p = 0.008) and risk of falls (p = 0.008), as well as for self-perceived walking capacity at one week (p = 0.017) and four weeks (p = 0.011) and quality of life at four weeks (p = 0.014). Regarding the comparison between groups, only significant results were obtained in the physical domain of the quality of life at four weeks (p = 0.014).

CONCLUSIONS

DN seems to be a promising therapeutic tool for the treatment of gait disorders in pwMS. However, when results were compared with sham DN, no differences were found.

Dry Needling for Arthrogenic Muscle Inhibition of Quadriceps Femoris in Patients after Reconstruction of Anterior Cruciate Ligament: a Protocol for a Randomized Controlled Trial

Background

: Dry needling (DN) is recommended as a therapeutic modality for various neuromusculoskeletal disorders. No study has been performed on the impact of DN on arthrogenic muscle inhibition (AMI) after anterior cruciate ligament reconstruction (ACLR). This study protocol is aimed to investigate the impacts of DN on AMI of quadriceps femoris, corticomotor, and spinal reflex excitability in patients with ACLR.

Methods

: A double-blind, between-subject, randomized, controlled trial will be conducted to measure changes in AMI after DN. Twenty-four subjects with ACLR will be recruited to receive a DN or a sham DN, providing that they met the inclusion criteria. Three sessions of DN on the quadriceps femoris will be applied during a one-week period. The primary outcome measures are the active motor threshold, motor evoked potential, and Hmax - Mmax ratio. The secondary outcomes are the International Knee Documentation Committee subjective knee form questionnaire score and maximum quadriceps isometric torque. Data will be collected at baseline, immediately after the first session, after the third session, and at the one-month follow-up visit.

Discussion

: The results of this study will provide preliminary evidence regarding the effects of DN on AMI of quadriceps femoris in patients with ACLR.

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.

The Effect of dry Needling in Chronic Stroke with a complex Network Approach: A Case Study

Background: Dry Needling (DN) has been demonstrated to be effective in improving sensorimotor function and spasticity in patients with chronic stroke. Electroencephalogram (EEG) has been used to analyze if DN has effects on the central nervous system of patients with stroke. There are no studies on how DN works in patients with chronic stroke based on EEG analysis using complex networks. Objective: The aim of this study was to assess how DN works when it is applied in a patient with stroke, using the graph theory. Methods: One session of DN was applied to the spastic brachialis muscle of a 62-year-old man with right hemiplegia after stroke. EEG was used to analyze the effects of DN following metrics that measure the topological configuration: 1) network density, 2) clustering coefficient, 3) average shortest path length, 4) betweenness centrality, and 5) small-worldness. Measurements were taken before and during DN. Results: An improvement of the brain activity was observed in this patient with stroke after the application of DN, which led to variations of local parameters of the brain network in the delta, theta and alpha bands, and inclined towards those of the healthy control bands. Conclusions: This case study showed the positive effects of DN on brain network of a patient with chronic stroke.

Effects of dry needling and exercise therapy on post-stroke spasticity and motor function- protocol of randomized clinical trial

BACKGROUND

Spasticity is one of the most common problems after the first stroke. Dry needling (DN) has been presented as a new therapeutic approach used by physiotherapists for the management of post-stroke spasticity. This study aimed to determine whether the addition of exercise therapy to the DN results in better outcomes in wrist flexors spasticity, motor neuron excitability, motor function and range of motion (ROM) in patients with chronic stroke.

METHODS

We will use a single-blind randomized controlled trial (RCT) in accordance with the CONSORT guidelines. A total of 24 patients with stroke will be included from the University Rehabilitation Clinics. The outcome measures will include Modified Modified Ashworth Scale, H_max/M_max ratio, H-reflex latency, Action Research Arm Test, Fugl-Meyer Assessment, and wrist extension active and passive range of motion. Patients in the DN and exercise therapy group will undergo 4 sessions of deep DN in flexor carpi radialis and flexor carpi ulnaris muscles on the affected upper limb and exercise therapy. Participants in the DN group will only receive DN for target muscles. Clinical and neurophysiological tests will be performed at baseline, after four therapy sessions, and at three weeks' follow-up.

DISCUSSION

This study will provide evidence for additional effects of exercise therapy to DN in comparison to DN alone on wrist flexors spasticity, motor neuron excitability, upper-limb motor function, and ROM in patients with chronic stroke.

Effects of dry needling plus exercise therapy on post-stroke spasticity and motor function: A case report

BACKGROUND AND PURPOSE

The use of dry needling (DN) with other treatments may be more beneficial in managing post-stroke spasticity. We report the effects of DN plus exercise therapy (ET) on wrist flexor spasticity.

PATIENT PRESENTATION

The patient was a 45-year-old man with an 8-year history of stroke. The outcome measures included the Modified Modified Ashworth Scale (MMAS), H_max/M_max ratio, H-reflex latency, Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), and range of motion (ROM) which were assessed before (T1), after (T2), and after 3-week follow-up (T3).

CONCLUSION

The MMAS was improved at T2 from "3" to "2". The H_max/M_max decreased from 0.77 to 0.53 at T3. The H-reflex latency increased from 15.4 ms to 18.5 ms at T3. The wrist active and passive ROM increased ∼30° and ∼20° at T2, respectively. A 4-session DN plus ET may improve spasticity and ROM. No meaningful improvement was observed in function.

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).

Effectiveness of Dry Needling in the Management of Spasticity in Patients Post Stroke

OBJECTIVE

To determine the effectiveness of the dry needling technique (DNT) in the treatment of spasticity for individuals with stroke.

DESIGN

We reviewed the Embase, Pubmed/MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials (CENTRAL) databases. We also performed a manual search of the references that are included in the selected articles. Studies included were: i) randomized clinical trials (RCTs); ii) involving patients with a diagnosis of stroke; and iii) using DNT alone or in a multimodal treatment. Muscular spasticity was the primary outcome of the study. The additional outcomes included were: pressure pain sensitivity, range of motion and perception of pain. The analysis of the certainty of the evidence was analyzed using GRADE. The risk of bias of the included studies was assessed with the Cochrane Risk of Bias Tool for Randomized Controlled Trials.

RESULTS

A total of six RCTs with 221 patients were included in this systematic review, where a significant decrease in spasticity was observed in most of the muscles evaluated, though the certainty of the evidence was low. The effects were only evaluated in the short term in all included studies and the sample size was small.

CONCLUSION

These results should be taken with caution because the included studies are few in number and have different comparators. More RCTs are needed to cover aspects of biases found in the literature, in particular the blinding of participants and personnel.