Dry needling for the management of thoracic spine pain

Correlation between Anthropometric and Ultrasound Measurement for Dry Needling of the Iliocostalis Lumborum Muscle with a Safety Protocol: A Cross-Sectional Observational Study

INTRODUCTION

the management of musculoskeletal pain through the application of dry needling (DN) is effective. The application of this technique can carry very infrequent major risks on muscles, such as on the iliocostalis lumborum due to its proximity to the kidney and the peritoneum. It is important to establish a DN protocol based on the different anthropometric variables of the subjects.

MAIN OBJECTIVE

the main objective of this study was to investigate the correlation between different anthropometric variables and the skin-kidney and skin-peritoneum distances to establish the size of the needle that could perform DN in the iliocostalis lumborum muscle without risk.

DESIGN

a cross-sectional observational study was conducted.

METHODOLOGY

a total of 68 healthy subjects were evaluated. Demographic and anthropometric data, such as age, gender, weight, height, body mass index (BMI), chest (xiphoid process and axilla) and abdomen circumferences, and skinfold thickness were collected. The measurements of skin-upper and lower edge of the iliocostalis lumborum muscle and the skin-peritoneum and/or kidney in the regions of L2 and L4, and on both sides, were assessed using ultrasound imaging.

RESULTS

a multiple linear regression analysis was performed, confirming that, in L2 without compression, gender significantly predicted the distance, with the distance being greater in women than in men. The measurement without compression increased with age up to 50 years, and it also increased with higher measurements for the chest-triceps, iliac crest, and thigh skinfold thickness, and decreased with higher measurement for the abdominal circumference. It was verified that the measurement with compression in L2 decreased as the neutral axillary circumference and the skinfold thickness in the abdomen-iliac crest increased, while the distance increased with larger measurements obtained in the neutral abdominal circumference and in the skinfold thickness of the chest-triceps. It was also verified that the measurement with compression in L4 increased up to a body mass index of 25 and then decreased even if the index increased further, and it decreased as the skinfold thickness in the abdomen-iliac crest decreased and increased as the measurements of the neutral abdominal circumference and the skinfold thickness in the chest-triceps increased. In L4 without compression, the gender variable significantly predicted changes in the measurement, with women tending to have a smaller distance compared to men.

CONCLUSIONS

the measurements of the neutral abdominal circumference, chest-triceps, and abdomen-iliac crest skinfold thickness could help clinicians predict the skin-kidney and skin-peritoneum distances for dry needling of the iliocostalis lumborum with the methodology described.

Contracture Knots vs. Trigger Points. Comment on Ball et al. Ultrasound Confirmation of the Multiple Loci Hypothesis of the Myofascial Trigger Point and the Diagnostic Importance of Specificity in the Elicitation of the Local Twitch Response. Diagnostics 2022, 12, 321

A recent study published in Diagnostics attempted to visualize trigger points and contracture knots with high-definition ultrasound. Based on their findings, the authors reversed the commonly understood meaning of the two terms. However, they did so without providing any convincing evidence. The authors maintained that their sonography images represented trigger points within contracture knots, supporting the multiple loci hypothesis. On review of the paper, both conclusions seem premature and rather speculative.

Treatment of thoracic spine pain and pseudovisceral symptoms with dry needling and manual therapy in a 78-year-old female: A case report

DESIGN

Case Report.

BACKGROUND AND PURPOSE

Thoracic spine pain and movement dysfunction is a relatively common problem in the general population but has received little attention in research. Dry needling is frequently utilized by physical therapists and has been shown to reduce pain and improve function in areas, such as the cervical and lumbar spine, shoulder, hip, and knee. However, little research has been performed on the use of dry needling in the thoracic area with only two prior case studies being published. This case report documents the use of dry needling and manual therapy to treat a patient with symptoms of thoracic spine pain with concurrent pseudovisceral symptoms of chest pain and difficulty breathing.

CASE DESCRIPTION

The patient was a 78-year-old female who was referred to physical therapy with complaints of pain focused in her mid-thoracic spine radiating anteriorly into her chest. The patient underwent medical diagnostic tests prior to her referral to physical therapy to rule out cardiac pathology, pulmonary pathology, and fracture. She was treated with dry needling and manual therapy for a total of four sessions over a two-week period.

OUTCOMES

Fifteen days after her initial evaluation, the patient reported she was pain-free with a pain score of 0/10 on the VAS. She reported she was no longer taking pain medication or NSAIDS. She was able to return to normal daily activities without restriction and normal sleep pattern. Her score on the Oswestry disability index at intake was 42% impairment and 2% impairment after 4 treatments. At follow-up 6 weeks and 12 weeks after her discharge from physical therapy, the patient reported she continued to be pain-free.

Prediction model of rhomboid major and pleura depth based on anthropometric features to decrease the risk of pneumothorax during dry needling

BACKGROUND

Although most common adverse events associated with dry needling can be considered minor, serious adverse events including induced pneumothorax cannot be excluded, and safety instructions for reducing the risk of pleura puncture are needed.

OBJECTIVE

To investigate if anthropometric features can predict the rhomboid major muscle and pleura depth in a sample of healthy subjects to avoid the risk of pneumothorax during dry needling.

METHODS

A diagnostic study was conducted on 59 healthy subjects (52.5% male) involving a total of 236 measurements (both sides in maximum inspiration and expiration), to calculate the accuracy of a prediction model for both pleura and rhomboid depth, as assessed with ultrasound imaging, based on sex, age, height, weight, body mass index (BMI), breathing and chest circumference. A correlation matrix and a multiple linear regression analyses were used to detect those variables contributing significantly to the variance in both locations.

RESULTS

Men showed greater height, weight, BMI, thorax circumference and skin-to-rhomboid, rhomboid-to-pleura and skin-to-pleura distances (P < .001). Sex, BMI, and thorax circumference explained 51.5% of the variance of the rhomboid (P < .001) and 69.7% of pleura (P < .001) depth limit. In general, inserting a maximum length of 19 mm is recommended to reach the deep limit of rhomboid major decreasing the risk of passing through the pleura.

CONCLUSION

This study identified that gender, BMI and thorax circumference can predict both rhomboid and pleura depth, as assessed with ultrasonography, in healthy subjects. Our findings could assist clinicians in the needle length election in avoiding the risk of induced pneumothorax during dry needling.

[Effectiveness of invasive and non-invasive tecniques for neck myofascial pain syndrome: a systematic review]

INTRODUCTION

Myofascial pain is a muscular alteration caused by one or more myofascial trigger points and is considered one of the most frequent musculoskeletal disorders. This study compared the effectiveness of invasive and non-invasive techniques in the treatment of neck myofascial pain syndrome.

MATERIALS AND METHODS

A literature search were performed in PubMed with a combination of key words related to myofascial pain syndrome and invasive and non-invasive therapies. Articles were included according to whether they were published less than 10 years previously and other inclusion criteria. Pain intensity, pressure pain threshold, range of movement, disability and quality of life were evaluated in the 26 articles finally selected.

RESULTS

There are multiple publications on pain intensity reduction and range of movement. Reports of invasive techniques are more important than those of non-invasive techniques. However, there are only a few publications on threshold pressure pain, functionality and quality of life irrespective of the type of technique.

CONCLUSION

Invasive and non-invasive techniques are effective in the treatment of neck myofascial pain syndrome, but it is difficult to conclude the superiority of one type of technique over the other due to multiple methodological differences among the evaluated studies.

Enhancing Trigger Point Dry Needling Safety by Ultrasound Skin-to-Rib Measurement: An inter-Rater Reliability Study

Dry needling (DN) is a minimally invasive treatment technique widely used by physical therapists to treat myofascial trigger points (MTrP). Even if its safety has been commonly declared and the majority of adverse events are considered mild, serious adverse events cannot be excluded and DN treatments of several trunk muscles can potentially result in pneumothorax. Ultrasound imaging (US) skin-to-rib measurement could ensure the safety of this treatment procedure. Therefore, the aim of this study was to determine the inter-rater reliability of depth measurement of different trunk muscles (i.e., rhomboid, lower trapezius, iliocostalis, and pectoralis major) between an expert and two novice physiotherapists. Skin-to-rib distance of 26 asymptomatic and normal weights subjects was consecutively, independently, and randomly measured for each muscle by the three examiners (1 expert and 2 novice physical therapists) with a handheld US wireless probe. Intraclass correlation coefficient (ICC_3,k) and standard error of measurement (SEM) were used to assess inter-rater reliability. Inter-rater reliability of skin-to-rib measurements between the three examiners was good to excellent or excellent for every muscle, with an ICC_3,k ranging from 0.92 and 0.98 (95% CI 0.86–0.99). The SEM never exceeded 10% of the skin-to-rib distance. In conclusion, skin-to-rib US measurements of the trunk muscles can be reliably performed by novice physical therapists using a handheld US device. These measures could be used as an innovative and reliable technique to improve the safety of some potential dangerous DN treatments.

Safety of dry needling to the upper lumbar spine: a pilot cadaver study

Objective: When inserting a dry needle laterally into the upper lumbar spine (L1-L3) there is an increased risk of piercing the kidney; therefore, the objective of this study was to determine a zone of safety for practitioners to needle in the upper lumbar spine.Methods: Ten cadavers were screened for inclusion. L1 spinous process was identified and confirmed with ultrasound imaging. A digital caliper was used to measure laterally at 1.5 cm, 2.0 cm, and 2.5 cm. Dry needles were inserted maximally at each point and a binary decision, yes or no, was made to determine if bony contact was made. Needle depth and abdominal width measurements were also recorded. Safety of the dry needling procedure was interpreted as such if bony contact was made by the needle. If bony contact was made, then it was assumed that the needle cannot advance further into pleura or kidney.Results: Forty-four percent of needles did not make bony contact at 2.5 cm lateral of the L1 spinous process, whereas 22% did not make bony contact at 1.5 cm and 2.0 cm. There was a weak to moderate negative correlation between abdominal width measurements and needle depth at 1.5 cm (-0.48) and 2.0 cm (-0.45), and at 2.5 cm (-0.39).Conclusion: A safety zone of needling less than 2.5 cm is likely safe, but needs to be confirmed with future study. Dry needling 2.5 cm lateral appears more risky due to the higher frequency of not contacting a bony backdrop.

The relative risk to the femoral nerve as a function of patient positioning: potential implications for trigger point dry needling of the iliacus muscle

Objectives: Prudent dry needling techniques are commonly practiced with the intent to avoid large neurovascular structures, thereby minimizing potential excessive bleeding and neural injury. Patient position is one factor thought to affect the size of the safe zone during dry needling of some muscles. This study aimed to compare the size of the needle safe zone of the iliacus muscle during two different patient positions using ultrasound imaging. Methods: The distance from the anterior inferior iliac spine (AIIS) to the posterior pole of the femoral nerve was measured in 25 healthy participants (11 male, 14 female, mean age = 40) in both supine and sidelying positions using a Chison Eco1 musculoskeletal ultrasound unit. The average distance was calculated for each position and a two-tailed, paired t-test (α < 0.05) was used to examine the difference between positions. Results: The mean distance from the AIIS to the posterior pole of the femoral nerve was statistically greater with participants in the sidelying position (mean[SD] = 35.7 [6.2] mm) than in the supine position (mean[SD] = 32.1 [7.3] mm, p < .001). Discussion: Although more study is needed, these results suggest that patient positioning is one of several potential variables that should be considered in the optimization of patient safety/relative risk when performing trigger point dry needling. Level of Evidence: Level 4 (Pre-Post Test).

Widespread Pressure Pain Sensitivity and Referred Pain from Trigger Points in Patients with Upper Thoracic Spine Pain

Objectives

The presence of trigger points (MTrPs) and pressure pain sensitivity has been well documented in subjects with neck and back pain; however, it has yet to be examined in people with upper thoracic spine pain. The purpose of this study was to investigate the presence of MTrPs and mechanical pain sensitivity in individuals with upper thoracic spine pain.

Methods

Seventeen subjects with upper thoracic spine pain and 17 pain-free controls without spine pain participated. MTrPs were examined bilaterally in the upper trapezius, rhomboid, iliocostalis thoracic, levator scapulae, infraspinatus, and anterior and middle scalene muscles. Pressure pain thresholds (PPTs) were assessed over T2, the C5-C6 zygapophyseal joint, the second metacarpal, and the tibialis anterior.

Results

The numbers of MTrPs between both groups were significantly different (P < 0.001) between patients and controls. The number of MTrPs for each patient with upper thoracic spine pain was 12.4 ± 2.8 (5.7 ± 4.0 active TrPs, 6.7 ± 3.4 latent TrPs). The distribution of MTrPs was significantly different between groups, and active MTrPs within the rhomboid (75%), anterior scalene (65%), and middle scalene (47%) were the most prevalent in patients with upper thoracic spine pain. A higher number of active MTrPs was associated with greater pain intensity and longer duration of pain history.

Conclusions

This study identified active MTrPs and widespread pain hypersensitivity in subjects with upper thoracic spine pain compared with asymptomatic people. Identifying proper treatment strategies might be able to reduce pain and improve function in individuals with upper thoracic spine pain. However, future studies are needed to examine this.

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

Myofascial trigger points are not an isolated neuromusculoskeletal phenomenon and have been implicated in systemic, visceral, and metabolic pathology, as a side effect of some medications and in the presence of psychological risk factors. This complexity can complicate adequate screening of patients prior to choosing dry needling as a treatment intervention. Regardless of whether clinicians practice in a direct access setting, they should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dry-needling appropriateness, technique chosen, and potential adverse responses to treatment. Of primary concern are conditions that can either manifest with myalgia and/or myopathy or masquerade as a more common musculoskeletal condition. This clinical commentary reviews system-specific considerations and other common disorders that should be screened for and discusses not only whether dry needling is appropriate but comments on technique and dosage considerations when initiating dry needling.

Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial

Study Design Prospective, randomized, partially blinded. Background Greater trochanteric pain syndrome (GTPS) is the current terminology for what was once called greater trochanteric or subgluteal bursitis. Cortisone (corticosteroid) injection into the lateral hip has traditionally been the accepted treatment for this condition; however, the effectiveness of injecting the bursa with steroids is increasingly being questioned. An equally effective treatment with fewer adverse side effects would be beneficial. Objective To investigate whether administration of dry needling (DN) is noninferior to cortisone injection in reducing lateral hip pain and improving function in patients with GTPS. Methods Forty-three participants (50 hips observed), all with GTPS, were randomly assigned to a group receiving cortisone injection or DN. Treatments were administered over 6 weeks, and clinical outcomes were collected at baseline and at 1, 3, and 6 weeks. The primary outcome measure was the numeric pain-rating scale (0-10). The secondary outcome measure was the Patient-Specific Functional Scale (0-10). Medication intake for pain was collected as a tertiary outcome. Results Baseline characteristics were similar between groups. A noninferiority test for a repeated-measures design for pain and averaged function scores at 6 weeks (with a noninferiority margin of 1.5 for both outcomes) indicated noninferiority of DN versus cortisone injection (both, P<.01). Medication usage (P = .74) was not different between groups at the same time point. No adverse side effects were reported. Conclusion Cortisone injections for GTPS did not provide greater pain relief or reduction in functional limitations than DN. Our data suggest that DN is a noninferior treatment alternative to cortisone injections in this patient population. Level of Evidence Therapy, level 1b. Registered December 2, 2015 at www.clinicaltrials.gov (NCT02639039). J Orthop Sports Phys Ther 2017;47(4):232-239. Epub 3 Mar 2017. doi:10.2519/jospt.2017.6994.