Effectiveness of dry needling versus a classical physiotherapy program in patients with chronic low-back pain: a single-blind, randomized, controlled trial

Electrical dry needling versus a non-invasive multicomponent intervention in the treatment of myofascial trigger points in patients with chronic low back pain: A randomised clinical trial

OBJECTIVE

To compare the effects of electrical dry needling with a non-invasive multi-component intervention in patients with chronic low back pain.

DESIGN

A randomised single-blind clinical trial.

SETTING

Outpatient Physiotherapy Clinic; home.

PARTICIPANTS

Sixty-four patients with chronic low back pain aged 30-65 years.

INTERVENTIONS

Six-week electrical dry needling on myofascial trigger points, and a non-invasive multicomponent intervention (home exercise programme, stretching and ischemic compression).

MAIN MEASURES

Pain (Visual Analogue Scale), disability (Roland-Morris Disability Questionnaire and Oswestry Disability Index), kinesiophobia (Tampa Scale of Kinesiophobia), quality of life and sleep (Short Form 36-item Health Survey and Pittsburgh Sleep Quality Index), isometric endurance of trunk flexor muscles (McQuade test), lumbar mobility in flexion (finger-to-floor distance), and pressure pain threshold (algometer) were assessed at baseline, after 6 weeks, and after 2 months.

RESULTS

ANOVA showed statistically significant differences in group-by-time interaction for most pain pressure thresholds of myofascial trigger points (P < 0.05), for disability (Roland-Morris Disability Questionnaire: F = 6.14, P = 0.016; and Oswestry Disability Index: F = 7.36, P = 0.009), for trunk anteflexion (F = 10.03, P = 0.002) and for habitual sleep efficacy (F = 6.65, P = 0.012), use of hypnotics (F = 4.77, P = 0.033) and total score of quality of sleep (F = 8.23, P = 0.006).

CONCLUSIONS

In comparison to a non-invasive multicomponent intervention, electrical dry needling has more positive effects on disability, pain intensity, kinesiophobia, and reducing patients' sensitivity to myofascial trigger points pressure, at post-treatment and at 2 months.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04804228. Registered on May 28th, 2021. Available at https://clinicaltrials.gov/ct2/show/NCT04804228.

Comparative effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with chronic low back pain

OBJECTIVES

Chronic low back pain (CLBP) can seriously impair the quality of life of patients and has a remarkable comorbidity with psychological symptoms, which, in turn, can further exacerbate the symptoms of CLBP. Psychological treatments are critical and nonnegligent for the management of CLBP, and thus, should attract sufficient attention. However, current evidence does not suggest the superiority and effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with CLBP.Thus, this study was designed to compare the effectiveness of nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP and to recommend preferred strategies for attenuating psychological symptoms in clinical practice.

METHODS

In this systematic review and network meta-analysis (NMA), PubMed, Embase Database, Web of Science, and Cochrane Library were searched from database inception until March 2022. Randomized clinical trials (RCTs) that compare different nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP were eligible. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was used. Four reviewers in pairs and divided into two groups independently performed literature selection, data extraction, and risk of bias, and certainty of evidence assessments. This NMA was conducted with a random effects model under a frequentist framework. The major outcomes were depression, anxiety, and mental health presented as the standardized mean difference (SMD) with the corresponding 95% CI.

RESULTS

A total of 66 RCTs that randomized 4806 patients with CLBP met the inclusion criteria. The quality of evidence was typically low or some risks of bias (47 out of 66 trials, 71.3%), and the precision of summary estimates for effectiveness varied substantially. In addition, 7 categories of interventions with 26 specific treatments were evaluated. For depression, mind body therapy (pooled SMD = -1.20, 95% CI: -1.63 to -0.78), biopsychosocial approach (pooled SMD = -0.41, 95% CI: -0.70 to -0.12), and physical therapy (pooled SMD = -0.26, 95% CI: -0.50 to -0.02) exhibited remarkable effectiveness in reducing depression compared with the control group. For managing anxiety, mind body therapy (pooled SMD = -1.35, 95% CI: -1.90 to -0.80), multicomponent intervention (pooled SMD = -0.47, 95% CI: -0.88 to -0.06), and a biopsychosocial approach (pooled SMD = -0.46, 95% CI: -0.79 to -0.14) were substantially superior to the control group. For improving mental health, multicomponent intervention (pooled SMD = 0.77, 95% CI: 0.14 to 1.39), exercise (pooled SMD = 0.60, 95% CI: 0.08 to 1.11), and physical therapy (pooled SMD = 0.47, 95% CI: 0.02-0.92) demonstrated statistically substantial effectiveness compared with the control group. The rank probability indicated that mind body therapy achieved the highest effectiveness in reducing depression and anxiety among patients with CLBP. Besides, the combined results should be interpreted cautiously based on the results of analyses evaluating the inconsistency and certainty of the evidence.

CONCLUSION

This systemic review and NMA suggested that nonpharmacological interventions show promise for reducing psychological symptoms among patients with CLBP. In particular, mind body therapy and a biopsychosocial approach show considerable promise, and mind body therapy can be considered a priority choice in reducing depression and anxiety. These findings can aid clinicians in assessing the potential risks and benefits of available treatments for CLBP comorbidity with psychological symptoms and provide evidence for selecting interventions in clinical practice. More RCTs involving different interventions with rigorous methodology and an adequate sample size should be conducted in future research.

Duration of Electro-Dry Needling Does Not Change the Pain Response After Repeated Nociceptive Thermal Stimuli in Asymptomatic Individuals: A Randomized Intervention Study

Objective

To assess the effects of 5 different durations of electro-dry needling (EDN) on asymptomatic individuals' pain response after repeated noxious thermal stimuli.

Design

Randomized, non-controlled intervention trial.

Setting

University laboratory.

Participants

Asymptomatic participants (N=50) were recruited for the study and randomized into 5 groups. There were 33 women with an average age of 26.8 (±4.8) years. To participate in the study, individuals had to be between the ages of 18 and 40, free of any musculoskeletal injury which prevented participation of daily activities, and not pregnant or trying to become pregnant.

Interventions

Participants were randomly assigned to receive 5 different durations of EDN: 10, 15, 20, 25, and 30 minutes. To perform the EDN, 2 monofilament needles were inserted lateral to the lumbar spinous processes of L3 and L5 on the right. Needles were left in situ with electrical stimulation at a frequency of 2 Hz and an amplitude which resulted in a 3 to 6 out of 10 intensity pain rating by the participant.

Main Outcome Measures

The change in the magnitude of pain in response to repetitive heat-pulses before and after the EDN procedure.

Results

There was a significant reduction in the magnitude of pain in response across the groups after EDN (F_(1,42)=94.12, P<.001, ƞ_p²=.691). However, the interaction between time and group was not significant (F_(4,42)=1.019, P=.409, ƞ_p²=.088), indicating that no duration of EDN was superior to another in reducing temporal summation.

Conclusions

This study suggests that in asymptomatic individuals, performing EDN beyond 10 minutes does not provide any additional benefits in the reduction of the magnitude of pain in response to thermal nociceptive stimuli. Additional study in symptomatic populations is required for generalizability in clinical settings.

Dry needling for the treatment of acute myofascial pain syndrome in general practitioners' clinics: a cohort study

BACKGROUND

Musculoskeletal pain is one of the leading complaints in the ambulatory setting. There are many ways to treat it, including pharmacologic and non-pharmacologic approaches. Dry needling (DN) is an option that is easy to learn, cheap and has a good safety profile. The aim of this study was to assess the association between DN performed by GPs for acute myofascial pain syndrome (MPS) and pain relief and to evaluate factors associated with treatment success.

METHODS

In this prospective cohort study, two GPs performed DN in their clinics. Patients were asked to rank their pain using the Short-Form McGill Pain Questionnaire (SF-MPQ) before, 10-min and 1-week after the procedure. The SF-MPQ index consists of 3 parts; visual analog scale (VAS), pain rating index (PRI) and present pain intensity (PPI). Logistic regressions were performed to assess the variables associated with short- and medium- term success.

RESULTS

Fifty two patients were recruited from September 2019 until August 2020. VAS was 6.0 ± 2.3 (before), 4.1 ± 2.5 (10-min after) and 2.6 ± 2.71 (1-week after), P < 0.05. PRI was 17 ± 9.1 (before), 10.8 ± 8.5 (10-min after) and 5.1 ± 6.5 (1-week after), P < 0.05. PPI was 2.6 ± 1.0 (before), 1.7 ± 1.0 (10-min after) and 1.1 ± 1.2 (1-week after), P < 0.05. Short-term success was associated with the physician who performed the procedure (OR 10.08, 95% CI 1.15,88.4) and with the use of a single needle (vs. multiple needles inserted) (OR 4.55, 95% CI 1.03,20.11). Medium-term success was associated with being a native born (non-immigrant), OR 8.59, 95% CI 1.11,66.28 and with high level of initial pain, OR 11.22, 95% CI 1.82,69.27.

CONCLUSION

Our study demonstrated improvement in acute pain 10-min and 1-week after DN performed by a GP, in all parts of the SF-MPQ. Therefore, we believe DN is a good therapeutic option for GPs to aid patients suffering from MPS.

The effectiveness of dry needling in patients with chronic low back pain: a prospective, randomized, single-blinded study

Dry needling (DN) is a standard procedure for treating musculoskeletal disorders. However, there are no clear recommendations for using DN in low back pain (LBP). Therefore, this study aimed to assess the effectiveness of the novel DN program for reducing pain intensity and improving functional efficiency in patients with chronic LBP. A group of 40 patients with chronic LBP due to the L5-S1 discopathy were eligible and randomized into experimental (n = 20) and control (n = 20) groups. The DN program was performed for the experimental group according to the Five Regulatory Systems (FRS) concept. The control group received sham therapy using placebo needles. DN sessions were performed twice a week for 4 weeks. A single needling application lasted 60 min. Both groups received standard treatment and physical exercise of LBP for 1 month. Subjective pain was measured by a visual analog scale (VAS), functional efficiency was assessed with the Oswestry Disability Index (ODI), and the lower spine range of motion was measured with the Schober test. There were significant differences in pain reduction (VAS) in both groups (p < 0.001). The strongest analgesic effect in the DN group yielded 6.45 points immediately after the therapy, 6.2 points after 1 month, and 6 points after 3 months. The DN group scored higher VAS reduction than the control group (p < 0.001). There were significant differences in the functional state (ODI) in the experimental group (p < 0.001). There was a significant ODI decrease by 18.1 points, after 1 month by 18.9 points, and after 3 months by 17.6 points. No significant differences were found in the control group (p > 0.05). Intergroup differences were observed in the functional efficiency in ODI in all measurement time-points (p < 0.001). There were significant differences in the range of motion (Schober test) in the DN group (main effect: p < 0.001). For all measurements, differences (p < 0.001) were observed in favor of DN compared to the control. In conclusion, DN program according to the FRS concept stands for the novel treatment method supplemented by an exercise program, effectively reducing pain and improving functional efficiency in LBP patients.

Treatments for kinesiophobia in people with chronic pain: A scoping review

Kinesiophobia is associated with pain intensity in people suffering from chronic pain. The number of publications highlighting this relationship has increased significantly in recent years, emphasizing the importance of investigating and synthesizing research evidence on this topic. The purpose of this scoping review was to answer the following questions: (1) What types of interventions have been or are currently being studied in randomized controlled trials (RCTs) for the management of kinesiophobia in patients with chronic pain? (2) What chronic pain conditions are targeted by these interventions? (3) What assessment tools for kinesiophobia are used in these interventions? According to the studies reviewed, (1) physical exercise is the most commonly used approach for managing irrational fear of movement, (2) interventions for kinesiophobia have primarily focused on musculoskeletal pain conditions, particularly low back pain and neck pain, and (3) the Tampa Scale of Kinesiophobia is the most commonly used tool for measuring kinesiophobia. Future RCTs should consider multidisciplinary interventions that can help patients confront their irrational fear of movement while taking into account the patient’s personal biological, psychological, and social experiences with pain and kinesiophobia.

Asymmetric Biomechanical Properties of the Paravertebral Muscle in Elderly Patients With Unilateral Chronic Low Back Pain: A Preliminary Study

Background: Clinical incidences of chronic low back pain among the elderly are increasing. However, studies have not fully elucidated on changes in biomechanical properties of paravertebral muscles in patients with unilateral chronic low back pain. We evaluated the changes in biomechanical properties of painful and non-painful paravertebral muscles in elderly patients with unilateral chronic low back pain.

Methods: Biomechanical properties of paravertebral muscles, including muscle tone and stiffness, in elderly patients with unilateral chronic low back pain were measured using MyotonPRO. Lumbar Lordosis and Sacral Slope were measured by magnetic resonance imaging. Cross-sectional areas of paravertebral muscles were evaluated using ImageJ software version 1.53. Chronic low back pain severity was assessed by Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores. The correlations between VAS scores, ODI scores, Lumbar Lordosis, Sacral Slope, cross-sectional areas (painful side), disease duration, and biomechanical properties of paravertebral muscles in the painful side were analyzed.

Results: A total of 60 elderly patients with unilateral chronic low back pain were enrolled in this study. The muscle tone and stiffness of paravertebral muscles on the painful side were significantly higher than those on the non-painful side (p &lt; .05). Cross-sectional areas of paravertebral muscles on the painful side at the L3 level were smaller than those of the non-painful side (p &lt; .05). The VAS scores and ODI scores were significantly positively correlated with muscle tone and stiffness of paravertebral muscles on the painful side (p &lt; .05 and p &lt; .01, respectively). There were no significant correlations between disease duration, cross-sectional areas (painful side), Lumbar Lordosis, or Sacral Slope and muscle tone and stiffness of paravertebral muscles on the painful side (p &gt; .05).

Conclusion: In elderly patients with unilateral chronic low back pain, muscle tone and stiffness of paravertebral muscles on the painful side are higher than for those on the non-painful side. The asymmetry of biomechanical properties of paravertebral muscles is associated with severity of chronic low back pain.

Korean Medicine Clinical Practice Guidelines for Lumbar Herniated Intervertebral Disc in Adults: Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE)

A significant number of individuals suffer from low back pain throughout their lifetime, and the medical costs related to low back pain and disc herniation are gradually increasing in Korea. Korean medicine interventions have been used for the treatment of lumbar intervertebral disc herniation. Therefore, we aimed to update the existing Korean medicine clinical practice guidelines for lumbar intervertebral disc herniation. A review of the existing guidelines for clinical treatment and analysis of questionnaires targeting Korean medicine doctors were performed. Subsequently, key questions on the treatment method of Korean medicine used for disc herniation in actual clinical trials were derived, and drafts of recommendations were formed after literature searches using the Grading of Recommendations, Assessment, Development and Evaluation. An expert consensus was reached on the draft through the Delphi method and final recommendations were made through review by the development project team and the monitoring committee. Fifteen recommendations for seven interventions for lumbar disc herniation were derived, along with the grade of recommendation and the level of evidence. The existing Korean medicine clinical practice guidelines for lumbar intervertebral disc herniation have been updated. Continuous updates will be needed through additional research in the future.

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

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

Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To investigate the effect and safety of acupuncture for the treatment of chronic spinal pain.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, the WHO Clinical Trial Registry, and the US National Library of Medicine clinical trial registry were searched from January 1, 2000, to November 1, 2019. Randomized controlled trials (RCTs) involving patients with chronic spinal pain treated by acupuncture versus sham acupuncture, no treatment, or another treatment were included.

RESULTS

Data was extracted from 22 RCTs including 2588 patients. Pooled analysis revealed that acupuncture can reduce chronic spinal pain compared to sham acupuncture (weighted mean difference [WMD] -12.05, 95% confidence interval [CI] -15.86 to -8.24), mediation control (WMD -18.27, 95% CI -28.18 to -8.37), usual care control (WMD -9.57, 95% CI -13.48 to -9.44), and no treatment control (WMD -17.10, 95% CI -24.83 to -9.37). In terms of functional disability, acupuncture can improve physical function at immediate-term follow-up (standardized mean difference [SMD] -1.74, 95% CI -2.04 to -1.44), short-term follow-up (SMD -0.89, 95% CI -1.15 to -0.62), and long-term follow-up (SMD -1.25, 95% CI -1.48 to -1.03).

CONCLUSION

In summary, compared to no treatment, sham acupuncture, or conventional therapy such as medication, massage, and physical exercise, acupuncture has a significantly superior effect on the reduction in chronic spinal pain and function improvement. Acupuncture might be an effective treatment for patients with chronic spinal pain and it is a safe therapy.

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.

Effectiveness of Dry Needling Therapy on Pain, Hip Muscle Strength, and Physical Function in Patients With Hip Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To investigate the short-term effects of dry needling (DN) on physical function, pain, and hip muscle strength in patients with hip osteoarthritis (OA).

DESIGN

A double-blind, placebo-control, randomized controlled trial.

SETTING

Private practice physiotherapy clinic.

PARTICIPANTS

Patients with unilateral hip OA (N=45) were randomly allocated to a DN group, sham DN group, or control group.

INTERVENTIONS

Patients in the DN and sham groups received 3 treatment sessions. Three active myofascial trigger points (MTrPs) were treated in each session with DN or a sham needle procedure. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae, and gluteus minimus muscles.

MAIN OUTCOME MEASURES

Physical function was assessed with the Western Ontario and McMaster Universities (WOMAC) physical function subscale, the timed Up and Go test, and the 40-meter self-paced walk test. Intensity of hip pain related to physical function was evaluated using the visual analog scale and WOMAC pain subscale. The maximal isometric force of hip muscles was recorded with a handheld dynamometer.

RESULTS

Significant group by time interactions were shown for physical function, pain, and hip muscle force variables. Post hoc tests revealed a significant reduction in hip pain and significant improvements in physical function and hip muscle strength in the DN group compared with the sham and control groups. The DN group showed within- and between-groups large effect sizes (d>0.8).

CONCLUSIONS

DN therapy in active MTrPs of the hip muscles reduced pain and improved hip muscle strength and physical function in patients with hip OA. DN in active MTrPs of the hip muscles should be considered for the management of hip OA.

Efficacy of silver needle therapy for the treatment of chronic nonspecific low back pain: a prospective, single-center, randomized, parallel-controlled clinical trial

BACKGROUND

Chronic nonspecific low back pain (CNSLBP) troubles approximately 30% of people worldwide. Silver needle therapy (SNT) is a treatment method to relieve soft tissue pain through heating. Therefore, this study aimed to observe the effects of SNT on CNSLBP.

METHODS

In this study, 100 patients were randomly divided into 2 groups: silver needle (SN) group and control group (n = 50). In the SN group, patients received SNT and physiotherapy, while patients received physiotherapy alone in the control group. At the 6-month follow-up, the numerical rating scale (NRS), Oswestry Disability Index (ODI), Short-Form 12 of quality of life (SF-12), the natural logarithms of low-frequency measurement (InLF), and the natural logarithms of high-frequency measurement (InHF) of heart rate variability (HRV) were recorded.

RESULTS

In both groups, NRS, ODI, SF-12 scores, and HRV at 2 weeks after treatment were improved and maintained for 6 months. Compared with the control group, more significant improvements were observed in the NRS and SF-12 scores at 1, 2, 3, and 6 months and in the ODI scores at 1 and 2 months in the SN group (P <  0.05). However, there was no significant difference between the groups in the ODI scores at 3 and 6 months. InLF and InHF in the SN group were higher than those in the control group at 3 and 6 months (P <  0.05).

CONCLUSIONS

SNT relieved pain and improved quality of life and autonomic nerve activity, especially parasympathetic nerve, in patients with CNSLBP, without serious complications.

TRIAL REGISTRATION

Chinese Clinical Trial Registry No. ChiCTR-OOC-17013237 . Registered on November 11, 2017.

Combination of Gluteal Trigger Points Dry Needling and Percutaneous Endoscopic Lumbar Discectomy for Complex Low Back-Related Leg Pain

Purpose

Causes of low back-related leg pain (LBLP) can be complex and diverse. A detailed medical history, physical examination, laboratory tests, and imaging are necessary to accurately distinguish the pathomechanisms of LBLP and determine the most appropriate treatment.

Case

In this study, we report the first documented case in which the combination of dry needling (DN) and percutaneous endoscopic lumbar discectomy (PELD) was used for a patient with active myofascial trigger points (MTrPs) in the gluteus minimus muscle as well as L3-4 lumbar disc herniation (LDH). This 63-year-old woman complained of LBLP for 3 months. After careful examination and analysis, we determined this pain originated from two active MTrPs in the gluteal region and not LDH in L3-4. We first performed MTrPs DN, and the patient's LBLP was relieved completely. We then performed PELD at the L3-4 level for residual numbness on the medial and anterior aspect of the left lower limb. Finally, the patient received a satisfactory result.

Conclusion

The gluteal MTrPs test may be used as a routine examination for patients with LBLP, especially when clinical findings are discordant with imaging results.

Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review

OBJECTIVE

The objective of this study was to conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.

METHODS

MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points," "trigger point," "myofascial trigger point," "myofascial trigger points," "myofascial pain," and "myofascial pain syndrome." The MeSH keywords were combined by using Boolean operators "OR"/"AND." All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least 1 active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.

RESULTS

Of 478 possibly relevant publications, 198 met the inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the 6 criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness," "referred pain," and "local twitch response" (n=28 studies, 22%).

CONCLUSIONS

A number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain, and local twitch response were the 3 most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.

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.

Effect of Physical Exercise Programs on Myofascial Trigger Points-Related Dysfunctions: A Systematic Review and Meta-analysis

OBJECTIVE

Myofascial pain syndrome is one of the primary causes of health care visits. In recent years, physical exercise programs have been developed for the treatment of myofascial trigger points, but their effect on different outcomes has not been clarified. Thus, this study aimed to assess the effect of physical exercise programs on myofascial trigger points.

METHODS

A systematic search was conducted in Pubmed, Web of Science, and Scopus. Articles analyzing the effect of physical exercise programs on pain intensity, pressure pain threshold, range of motion, and disability were included. Risk of bias was assessed using the Cochrane RoB2 tool. The DerSimonian-Laird method was used to compute the pooled effect sizes (ES) and their 95% confidence interval (95% CI) for pain intensity, pressure pain threshold, range of motion, and disability.

RESULTS

A total of 24 randomized controlled trials were included in this systematic review and meta-analysis. The pooled ES were -0.47 (95% CI = -0.61 to -0.33) for pain intensity, 0.63 (95% CI = 0.31 to 0.95) for pressure pain threshold, 0.43 (95% CI = 0.24 to 0.62) for range of motion, and -0.18 (95% CI = -0.45 to 0.10) for disability.

CONCLUSIONS

Physical exercise programs may be an effective approach in the treatment of pain intensity, pressure pain threshold, and range of motion among patients with myofascial trigger points.

Dry needling for spine related disorders: a scoping review

Introduction/Background

The depth and breadth of research on dry needling (DN) has not been evaluated specifically for symptomatic spine related disorders (SRD) from myofascial trigger points (TrP), disc, nerve and articular structures not due to serious pathologies. Current literature appears to support DN for treatment of TrP. Goals of this review include identifying research published on DN treatment for SRD, sites of treatment and outcomes studied.

Methods

A scoping review was conducted following Levac et al.’s five part methodological framework to determine the current state of the literature regarding DN for patients with SRD.

Results

Initial and secondary search strategies yielded 55 studies in the cervical (C) region (71.43%) and 22 in the thoracolumbar-pelvic (TLP) region (28.57%). Most were randomized controlled trials (60% in C, 45.45% in TLP) and clinical trials (18.18% in C, 22.78% in TLP). The most commonly treated condition was TrP for both the C and TLP regions. In the C region, DN was provided to 23 different muscles, with the trapezius as treatment site in 41.88% of studies. DN was applied to 31 different structures in the TLP region. In the C region, there was one treatment session in 23 studies (41.82%) and 2–6 treatments in 25 (45.45%%). For the TLP region, one DN treatment was provided in 8 of the 22 total studies (36.36%) and 2–6 in 9 (40.9%). The majority of experimental designs had DN as the sole intervention. For both C and TLP regions, visual analogue scale, pressure pain threshold and range of motion were the most common outcomes.

Conclusion

For SRD, DN was primarily applied to myofascial structures for pain or TrP diagnoses. Many outcomes were improved regardless of diagnosis or treatment parameters. Most studies applied just one treatment which may not reflect common clinical practice. Further research is warranted to determine optimal treatment duration and frequency. Most studies looked at DN as the sole intervention. It is unclear whether DN alone or in addition to other treatment procedures would provide superior outcomes. Functional outcome tools best suited to tracking the outcomes of DN for SRD should be explored.

ADVERSE EVENTS ASSOCIATED WITH THERAPEUTIC DRY NEEDLING

BACKGROUND

There is a paucity of literature about the adverse events associated with Therapeutic Dry Needling (TDN). Much of the literature surrounding adverse events associated with TDN has been extrapolated from the acupuncture literature. Given that acupuncture and TDN are distinctly different in their application and proposed mechanisms, adverse events associated with TDN should be examined specifically.

PURPOSE

To determine and report the type of adverse events associated with the utilization of TDN.

STUDY DESIGN

Prospective Questionnaire.

METHODS

Four hundred and twenty physical therapists participated in this study. Information related to minor and major adverse events that occurred during 20,464 TDN treatment sessions was collected. Each physical therapist respondent was asked to fill out two weekly self-reported electronic surveys over a six-week period. One survey was related to "minor adverse events" (i.e. pain, bleeding, bruising), while the other was related to "major adverse events" (i.e. pneumothorax, excessive bleeding, prolonged aggravation). Following the six-week period, descriptive statistics were used to describe the adverse events (AE) associated with TDN and calculate the frequencies of those events.

RESULTS

A total of 7,531 minor AE's were reported, indicating that 36.7% of the reported TDN treatments resulted in a minor AE. The top three minor AE's were bleeding (16%), bruising (7.7%), and pain during dry needling (5.9 %). The average ratio of minor AE's for all respondents across all weeks was 0.53 or approximately one event for every two patients. Twenty major AE's were reported out of the 20,494 treatments for a rate of <0.1% (1 per 1,024 TDN treatments). No associations were noted between the frequency of adverse events and the number of patients treated, practitioner age, level of education, years in practice, level of training or months experience with dry needling.

CONCLUSION

Expected minor AE's such as mild bleeding, bruising, and pain during TDN were common and major AE's were rare. Physical therapists and other medical practitioners need to be aware of the risks of TDN. Based on the findings of this study the overall risk of a major adverse event during TDN is small.

LEVEL OF EVIDENCE

3, survey research.

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.

Proteins and Signaling Pathways Response to Dry Needling Combined with Static Stretching Treatment for Chronic Myofascial Pain in a RAT Model: An Explorative Proteomic Study

A quantitative proteomic analysis of the response to dry needling combined with static stretching treatment was performed in a rat model of active myofascial trigger points (MTrPs). 36 rats were divided into a model group (MG), a stretching group (SG) and a dry needling combined with stretching group (SDG). We performed three biological replicates to compare large-scale differential protein expression between groups by tandem mass tag (TMT) labeling technology based on nanoscale liquid chromatography mass spectrometry analysis (LC–MS/MS). Hierarchical clustering, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment and protein-protein interaction network analyses were performed for the general characterization of overall enriched proteins. For validation of the results of TMT, the candidate proteins were verified by parallel reaction monitoring (PRM) analysis. 285 differentially expressed proteins between groups were identified and quantified. Tight junction pathway played a dominant role in dry needling combined with static stretching treatment for the rat model of active MTrPs. Three candidate proteins, namely actinin alpha 3, calsequestrin-1 and parvalbumin alpha, were further validated, consistent with the results of LC–MS/MS. This is the first proteomics-based study to report the therapeutic mechanism underlying dry needling and static stretching treatment for MTrPs. Further functional verification of the potential signaling pathways and the enriched proteins is warranted.

The effect of exercise therapy, dry needling, and nonfunctional electrical stimulation on radicular pain: a case report

A 43-year-old male, office worker with history of chronic radicular low back pain radiating into the left leg was admitted to a sports medicine research center, neuroscience institute. During the past year, he visited a physiotherapist and orthopedic experts. Magnetic resonance imaging revealed a protruded disc at L4–5 level. Additionally, electromyography indicated that there was bilateral moderate irritation at the L5–S1 root. We designed a management package including exercise therapy, dry needling, and nonfunctional electrical stimulation for four sessions. Outcomes included pain intensity, pain with lumbar flexion, with the numerical rating scale (NRS), visual analogue scale (VAS), and function measured with the Oswestry Disability Index before and after the intervention. After 4 treatment sessions, the patient reported a reduction in pain intensity from a 9 to 2 on the NRS and from 90 to 30 on the VAS. In addition, the patient was able to perform lumbar flexion fully without pain.