Prediction Model of Soleus Muscle Depth Based on Anthropometric Features: Potential Applications for Dry Needling

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.

A Procedure for Measuring Anterior Scalene Morphology and Quality with Ultrasound Imaging: An Intra- and Inter-rater Reliability Study

OBJECTIVE

Ultrasound (US) imaging is an essential tool for clinicians because of its cost-effectiveness and accessibility for assessing multiple muscle metrics including muscle quality, size and shape. Although previous studies highlighted the importance of the anterior scalene muscle (AS) in patients with neck pain, studies analyzing the reliability of US measurements for this muscle are lacking. This study aimed to develop a protocol for assessing AS muscle shape and quality measured with US and investigating its intra- and inter-examiner reliability.

METHODS

Through use of a linear transducer, B-mode images of the anterolateral neck region at the C7 level were acquired in 28 healthy volunteers by two examiners (one experienced and one novel). Cross-sectional area, perimeter, shape descriptors and mean echo-intensity were measured twice by each examiner in randomized order. Intra-class correlation coefficients (ICCs), standard errors of measurement and minimal detectable changes were calculated.

RESULTS

Results indicated no muscle side-to-side asymmetries (p > 0.05). Gender differences were found for muscle size (p < 0.01), but muscle shape and brightness were comparable (p > 0.05). Intra-examiner reliability was good to excellent for all metrics for the experienced and (ICC >0.846) and novel (ICC >780) examiners. Although inter-examiner reliability was good for most of the metrics (ICC >0.709), the estimates for assessing solidity and circularity were unacceptable (ICC <0.70).

CONCLUSION

This study found that the described ultrasound procedure for locating and measuring anterior scalene muscle morphology and quality is highly reliable in asymptomatic individuals.

Inclusion of cross-sectional and radiological images for better understanding of musculoskeletal anatomy and decreasing the risk of adverse events during dry needling in undergraduate physiotherapy students

Since there is an increasing rate of physiotherapists using invasive procedures during the clinical practice, understanding the cross-sectional anatomy and radiological images is essential for ensuring patients' safety during these interventions. Therefore, the aim of this study was to analyze the students' opinion of including cross-sectional and radiological images to traditional methodologies, to evaluate whether these additional resources improve their ability to identify musculoskeletal structures in radiological images and their understanding of neurovascular and visceral structures related with specific muscles to be avoided during invasive procedures. First-year undergraduate physiotherapy students were enrolled in the study. A brief online survey asking about their opinion about the use of cross-sectional and radiological images as complementary resources was built. In addition, two open-answer tests (before and after the inclusion of these resources) were conducted to evaluate their ability to identify correctly musculoskeletal structures in magnetic resonance and ultrasound images and to evaluate their awareness of high-risk structures related with specific muscles. One-hundred-thirty-two students returned the online survey and one-hundred-forty-eight completed all the tests. In general, students opined cross-sectional images to be of utility for learning anatomy (81.8%) and radiological images (93.9%) and felt they benefited from cross-sectional and ultrasound images (78.0%). All tests showed significant improvements after the inclusion of these complementary resources (all, p < 0.001) except for trunk structures in MRI (p = 0.777). The implementation of anatomical cross-sectional and radiological images resulted in better understanding of radiological images and better cognition of possible risk during invasive procedures.

Correlation between Body Composition and Inter-Examiner Errors for Assessing Lumbar Multifidus Muscle Size, Shape and Quality Metrics with Ultrasound Imaging

Ultrasound imaging (US) is widely used in several healthcare disciplines (including physiotherapy) for assessing multiple muscle metrics such as muscle morphology and quality. Since measuring instruments are required to demonstrate their reliability, accuracy, sensitivity, and specificity prior to their use in clinical and research settings, identifying factors affecting their diagnostic accuracy is essential. Since previous studies analyzed the impact of sociodemographic but not body composition characteristics in US errors, this study aimed to assess whether body composition metrics are correlated with ultrasound measurement errors. B-mode images of the lumbar multifidus muscle at the fifth lumbar vertebral level (L5) were acquired and analyzed in 49 healthy volunteers by two examiners (one experienced and one novel). Cross-sectional area, muscle perimeter and mean echo intensity were calculated bilaterally. A multivariate correlation matrix was calculated for assessing the inter-examiner differences with body composition metrics. Results demonstrated excellent reliability (intraclass correlation coefficient, ICC > 0.9) for assessing the muscle cross-sectional area and perimeter, and good reliability for assessing the muscle shape and mean echo intensity (ICC > 0.7). Inter-examiner errors for estimating muscle size were correlated with participants' age (p value, p < 0.01), weight (p < 0.05), total and trunk lean mass (both, p < 0.01) and water volume (p < 0.05). Greater shape descriptors and mean brightness disagreements were correlated with older ages (p < 0.05) and total lean mass (p < 0.05). No correlations between age and body composition metrics were found (p > 0.05). This study found US to be a reliable tool for assessing muscle size, shape and mean brightness. Although aging showed no correlations with body composition changes in this sample, it was the main factor correlated with US measurement errors.

Regression Model Decreasing the Risk of Femoral Neurovascular Bundle Accidental Puncture

Although most of the adverse events derived from dry needling are minor, avoiding potential hazards for patients including accidental invasion of vessels, ganglia, and nerves is essential to ensure patients’ safety. We aimed to investigate the contribution of predictors explaining the variance of sartorius muscle depth limit at proximal third and middle thigh as these locations lead to an augmented risk of neurovascular bundle invasion during dry needling application. A diagnostic study was conducted on 84 subjects to calculate the accuracy of a prediction model for sartorius depth, as assessed with ultrasound imaging, based on sex, age, height, weight, body mass index (BMI), thigh perimeter, and length. After calculating a correlation matrix, a multiple linear regression analysis was performed to detect those variables contributing to the sartorius deep limit in both locations. Although males showed greater thigh perimeter than women (p < 0.001), the deep limit of the sartorius muscle was significantly more superficial for both the proximal third (p = 0.003) and the mid-third (p = 0.004) points. No side-to-side anthropometric differences were found (p > 0.05). In addition, we found sartorius muscle depth to be associated with the proximal and mid-third girth, gender, height, and BMI (all, p < 0.01). Gender, proximal-third girth, and BMI explained 51.1% and 42.6% of the variance for the sartorius deep limit at the proximal and the mid-third, respectively. This study analyzed whether anthropometric features could predict sartorius muscle depth in healthy participants for assisting clinicians in choosing the optimal needle length to avoid accidental femoral bundle puncture.

Accuracy and safety of dry needling placement in the popliteus muscle: A cadaveric study

BACKGROUND

The popliteus muscle attaches posteriorly to the joint capsule of the knee. Although it is an important rotational stabiliser and has been implicated in various knee pathologies, research on its treatment with dry needling is scarce.

OBJECTIVE

To determine if a needle accurately and safely penetrates the popliteus muscle during the clinical application of dry needling.

METHODS

A cadaveric descriptive study was conducted. Needling insertion of the popliteus muscle was conducted in 11 cryopreserved cadavers with a 50-mm needle. The needle was inserted at upper third of the posterior part of the tibia closest to the knee towards the popliteus. The needle was advanced into the muscle based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analysed by photometry. Safety of the intervention was assessed by calculating the distance from the tip of the needle to the proximate neurovascular structures.

RESULTS

Accurate needle penetration of the popliteus muscle was observed in 10 out of 11 (91%) of the cadavers (mean needle penetration: 25.7 ± 6.7mm, 95% CI 21.3-30.3 mm). The distances from the tip of the needle were 17±6mm (95% CI 13-21 mm) to the tibial nerve and 15 ± 0.7mm (95% CI 10-20 mm) to the popliteus vascular bundle.

CONCLUSION

The results from this cadaveric study support the notion that needling of the popliteus can be accurately and safely conducted by an experienced clinician. Future studies investigating the clinical effectiveness of these interventions are needed.

Is Dry Needling of the Supinator a Safe Procedure? A Potential Treatment for Lateral Epicondylalgia or Radial Tunnel Syndrome. A Cadaveric Study

The supinator muscle is involved in two pain conditions of the forearm and wrist: lateral epicondylalgia and radial tunnel syndrome. Its close anatomical relationship with the radial nerve at the arcade of Frohse encourages research on dry needling approaches. Our aim was to determine if a solid filiform needle safely penetrates the supinator muscle during the clinical application of dry needling. Needle insertion of the supinator muscle was conducted in ten cryopreserved forearm specimens with a 30 × 0.32 mm filiform needle. With the forearm pronated, the needle was inserted perpendicular into the skin at the dorsal aspect of the forearm at a point located 4cm distal to the lateral epicondyle. The needle was advanced to a depth judged to be in the supinator muscle. Safety was assessed by measuring the distance from the needle to the surrounding neurovascular bundles of the radial nerve. Accurate needle penetration of the supinator muscle was observed in 100% of the forearms (needle penetration:16.4 ± 2.7 mm 95% CI 14.5 mm to 18.3 mm). No neurovascular bundle of the radial nerve was pierced in any of the specimen’s forearms. The distances from the tip of the needle were 7.8 ± 2.9 mm (95% CI 5.7 mm to 9.8 mm) to the deep branch of the radial nerve and 8.6 ± 4.3 mm (95% CI 5.5 mm to 11.7 mm) to the superficial branch of the radial nerve. The results from this cadaveric study support the assumption that needling of the supinator muscle can be accurately and safely conducted by an experienced clinician.

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.

M-Mode Ultrasound Examination of Soleus Muscle in Healthy Subjects: Intra- and Inter-Rater Reliability Study

Objective: M-mode ultrasound imaging (US) reflects the motion of connective tissue within muscles. The objectives of this study were to evaluate inter-rater and intra-rater reliability of soleus muscle measurements between examiners with different levels of US experience in asymptomatic subjects and to investigate the level of soleus muscle isometric activity in two positions (knee extended and knee flexed at 30°). Methods: Thirty volunteers without a history of ankle pain were evaluated with US examinations of the soleus muscle. Each muscle was scanned independently by two evaluators. Muscle at rest thickness, maximal isometric contraction thickness, time and velocity measures were detailed and blinded to the other examiner. Results: Intra- and inter-rater reliability at rest, in maximal isometric contraction thickness, contraction time and contraction velocity measures for both positions (extended and flexed knee) were reported from good to excellent for all outcome measurements. The position with the knee extended reported a statistically significant increase in thickness after motion showing 1.33 ± 0.27 mm for measurements at rest thickness with knee extended versus 1.50 ± 0.29 mm for measurements at end thickness with the knee in flexed position (p = 0.001), as well as 1.31 ± 0.23 mm for rest thickness with the knee in flexed position measurements with respect to 1.34 ± 0.24 mm for maximal isometric contraction thickness with extended knee measurements (p = 0.058). Conclusions: This study found that intra- and inter-examiner reliability of M-mode ultrasound imaging of the soleus muscle was excellent in asymptomatic subjects and the soleus muscle activity was different between the position with the knee extended and the position with the knee flexed.