Are There Trigger Points in the Spastic Muscles? Electromyographical Evidence of Dry Needling Effects on Spastic Finger Flexors in Chronic Stroke

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.

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 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.

New insights into acupuncture techniques for poststroke spasticity

With the trend of aging population getting more obvious, stroke has already been a major public health problem worldwide. As a main disabling motor impairment after stroke, spasticity has unexpected negative impacts on the quality of life and social participation in patients. Moreover, it brings heavy economic burden to the family and society. Previous researches indicated that abnormality of neural modulation and muscle property corelates with the pathogenesis of poststroke spasticity (PSS). So far, there still lacks golden standardized treatment regimen for PSS; furthermore, certain potential adverse-events of the mainstream therapy, for example, drug-induced generalized muscle weakness or high risk related surgery somehow decrease patient preference and compliance, which brings challenges to disease treatment and follow-up care. As an essential non-pharmacological therapy, acupuncture has long been used for PSS in China and shows favorable effects on improvements of spastic hypertonia and motor function. Notably, previous studies focused mainly on the research of antispastic acupoints. In comparison, few studies lay special stress on the other significant factor impacting on acupuncture efficacy, that is acupuncture technique. Based on current evidences from the clinic and laboratory, we will discuss certain new insights into acupuncture technique, in particular the antispastic needling technique, for PSS management in light of its potential effects on central modulations as well as peripheral adjustments, and attempt to provide some suggestions for future studies with respect to the intervention timing and course, application of acupuncture techniques, acupoint selection, predictive and aggravating factors of PSS, aiming at optimization of antispastic acupuncture regimen and improvement of quality of life in stroke patients. More innovations including rigorous study design, valid objective assessments for spasticity, and related experimental studies are worthy to be expected in the years ahead.

Neurointerface with oscillator motifs for inhibitory effect over antagonist muscles

The effect of inhibitory management is usually underestimated in artificial control systems, using biological analogy. According to our hypothesis, the muscle hypertonus could be effectively compensated via stimulation by bio-plausible patterns. We proposed an approach for the compensatory stimulation device as implementation of previously presented architecture of the neurointerface, where (1) the neuroport is implemented as a DAC and stimulator, (2) neuroterminal is used for neurosimulation of a set of oscillator motifs on one-board computer. In the set of experiments with five volunteers, we measured the efficacy of motor neuron inhibition via the antagonist muscle or nerve stimulation registering muscle force with and without antagonist stimulation. For the agonist activation, we used both voluntary activity and electrical stimulation. In the case of stimulation of both the agonist and the antagonist muscles and nerves, we experimented with delays between muscle stimulation in the range of 0-20 ms. We registered the subjective discomfort rate. We did not identify any significant difference between the antagonist muscle and nerve stimulation in both voluntary activity and electrical stimulation of cases showing agonist activity. We determined the most effective delay between the stimulation of the agonist and the antagonist muscles and nerves as 10-20 ms.

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.

Immediate Effect of Dry Needling at Myofascial Trigger Point on Hand Spasticity in Chronic Post-stroke Patients: A Multicenter Randomized Controlled Trial

Background: Hand spasticity after stroke influences the rehabilitation of hand function. Immediate and effective relief of spasticity potentially creates conditions for later rehabilitation training, which has far-reaching significance in the smooth transition of patients to the recovery period.

Objective: To evaluate the immediate effect of dry needling (DN) at myofascial trigger point on hand spasticity in stroke patients.

Methods: This was a prospective, evaluator blind, multicenter, randomized controlled study. A total of 210 participants were randomly divided into DN group (DN, N = 70), sham dry needling group (SDN, N = 70), and control group (N = 70). Participants in the DN group were treated with DN at myofascial trigger point five times (30 min each time) every week for 4 weeks. Subjects in the SDN group were manipulated the same way as in the DN group, except that the acupuncture site was located in the area adjacent to the myofascial trigger point, which constituted a SDN. Routine rehabilitation treatment was performed for participants in the two groups and in the control group. The primary evaluation index was the immediate effect of hand spasticity relief. Secondary evaluation indicators included the cumulative effect of hand spasticity relief from baseline to week 4, and the changes in flexion angles of the wrist, thumb, and fingers 2–5 in the rest position before, immediately after, and 4 weeks after intervention.

Results: The immediate effective rate of spasticity relief (thumb, fingers 2–5, and wrist) of patients with different degrees of spasticity in the DN group was higher than that in the control and SDN groups (thumb, χ² = 55.833, P < 0.001; fingers 2–5, χ² = 68.096, P < 0.001; wrist, χ² = 49.180, P < 0.001) (P < 0.05). The effective rate of spasticity relief from baseline to 4 weeks in the DN group exceeded that in the control group and SDN groups (thumb, χ² = 8.806, P = 0.012; fingers 2–5, χ² = 8.087, P = 0.018; and wrist, χ² = 8.653, P = 0.013) (P < 0.05). No difference in immediate and cumulative effect was found between the control group and SDN group. The change of joints flexion angles in resting position before and after each treatment in the DN group was higher than that in the control and SDN groups (P < 0.05), but it was not significantly different between the control group and SDN group. At 4 weeks, although the change in the DN group was higher than that in the control group and SDN group, this difference was not statistically significant (P > 0.05).

Conclusion: Dry needling can relieve varying degrees of hand spasticity instantly in post-stroke.

Trial Registration:www.chictr.org.cn, ChiCTR1900022379.

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.

Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects of muscle dry needling alone or combined with other interventions on post-stroke spasticity (muscle tone), related pain, motor function, and pressure sensitivity.

DATABASES AND DATA TREATMENT

Electronic databases were searched for randomized controlled trials including post-stroke patients where at least one group received dry needling and outcomes were collected on spasticity and related pain. Secondary outcomes included motor function and pressure pain sensitivity. Data were extracted by two reviewers. The risk of bias was assessed with the Cochrane Risk of Bias tool, methodological quality was assessed with the Physiotherapy Evidence Database score, and the quality of evidence was assessed by the Grading of Recommendations Assessment, Development, and Evaluation approach. Between-groups mean differences (MDs) and standardized mean differences (SMDs) were calculated.

RESULTS

Seven studies (three within the lower extremity, four in the upper extremity) were included. The meta-analysis found significantly large effect sizes of dry needling for reducing spasticity (SMD: -1.01, 95%confidence interval [CI] -1.68 to -0.34), post-stroke pain (SMD -1.01, 95%CI -1.73 to -0.30), and pressure pain sensitivity (SMD 1.21, 95% CI: 0.62 to 1.80) as compared with a comparative group at short-term follow-up. The effect on spasticity was found mainly in the lower extremity (MD -1.05, 95% CI: -1.32 to -0.78) at short-term follow-up. No effect on spasticity was seen at 4 weeks. No significant effect on motor function (SMD 0.16, 95% CI: -0.13 to 0.44) was observed. The risk of bias was generally low, but the imprecision of the results downgraded the level of evidence.

CONCLUSION

Moderate evidence suggests a positive effect of dry needling on spasticity (muscle tone) in the lower extremity in post-stroke patients. The effects on related pain and motor function are inconclusive.

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).

Dry needling for the management of spasticity, pain, and range of movement in adults after stroke: A systematic review

OBJECTIVE

To summarise the available evidence about the effectiveness of deep dry needling (DN) on spasticity, pain-related outcomes, and range-of-movement (ROM) in adults after stroke.

DESIGN

A computer search of Web of Science, Scopus, Medline, Cochrane Library, Cinahl, and Physiotherapy Evidence Database (PEDro) was conducted. A hand search of the reference lists of the selected studies and other relevant publications was also undertaken. Studies were assessed by two independent reviewers and included if they complied with the following criteria: (1) participants were adults after a stroke, (2) use of DN alone or within a multimodal approach, compared to no intervention or other treatments; (3) assessment of spasticity, pain, or joint ROM as a primary or secondary outcome. We included randomised controlled trials (RCTs), case series, and case reports. Data were extracted using a standardised protocol. The methodological quality of the studies was assessed with the Checklist for Measuring quality.

RESULTS

A total of sixteen studies, 7 of which were RCTs, were selected. All studies generally reported an improvement of spasticity level, pain intensity, and ROM after the use of DN, alone or combined with other interventions, in stroke survivors.

CONCLUSION

The management of adults after stroke with DN may impact positively on spasticity, pain, and ROM. However, there was significant heterogeneity across trials in terms of sample size, control groups, treated muscles, and outcome measures, and a meta-analysis was not feasible. Further research should include proper blinding, sham placebo DN as control intervention, and investigate long-term effects.