Needling the needy for pain erasure
Needling the needy for pain erasure
Dry Needling is a form of treatment that is used to treat musculoskeletal pain and dysfunctions. The mechanism of pain relief is not only mechanical but also neurophysiological. Similar to earlier years, 2019 had witnessed too many articles published on Dry Needling (DN). Apart from musculoskeletal conditions, dry Needling nowadays is employed in nonmusculoskeletal conditions like cancer pain, spasticity management, neuropathic pain, tension type headache, motor control, and complex regional pain syndromes etc. A couple of in-vitro and in-vivo anatomic validation studies on dry needling were also done to prove the correctness of needling angles and depth. About 58 articles were published in peer-reviewed journals in the year 2019. We have picked up 10 articles based on novelty, clinical utility and study quality. We aim to review these top ten articles published in 2019.
Sila Gildir, msc,a Emine Handan Tüzün, phd,a,* et al.
Medicine (Baltimore). 2019 Feb; 98(8):e14520
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This is a randomized, double-blinded trial that aimed to find the effectiveness of dry needling in chronic tension-type headache. 168 patients from 2 neurology clinics were chosen and divided in to dry needling group and sham group. One group received dry needling to the head and neck musculature and the other group received sham needling (placebo needling) in the non-trigger point area. Dry needling was applied to the active myofascial trigger points (MTrPs) located in masseter, temporalis, splenius cervicis, splenius capitis, upper trapezius and sub-occipital muscles. Needles remained in there for 20 minutes. 3 sessions of treatment for 2 weeks were given and the outcomes like headache intensity, frequency, duration and quality of life were compared before and after the intervention. Results found that trigger point dry needling is effective and safe in reducing tension type headache. This is a first high-quality randomized control trial investigating the effect of dry needling in chronic tension- type headache. Results suggested that physiotherapists can treat not only cervicogenic headache, but also tension- type headache, using dry needling. One limitation of the study is that there is no long term follow-up.
Zarei H1, Bervis S1, Piroozi S2, Motealleh A3.
Arch Phys Med Rehabil. 2019 Aug 26
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This study aimed to show the added effect of dry needling to gluteus medius(GM) and quadratus lumborum(QL) along with regular strengthening exercise in female athletes with patellofemoral pain (PFP). It is a single-blinded randomized control trial with 6 weeks follow-up. A convenience sample of 40 female athletes with PFP was randomized to exercise therapy group and exercise therapy plus dry needling group. The first group got 4 weeks of exercises and 4 sessions of dry needling (one session per week) and the second group received exercises without dry needling. Ipsilateral gluteus medius and contralateral quadratus lumborum were needled using 50 mm and 100 mm length needles respectively. Outcomes like pain intensity, function (Kujala score, modified star excursion balance test, step-down test), and QL & GM pressure pain threshold (PPT) were recorded at baseline and at 4 and 6 weeks after the start of treatment. The results showed that added DN of GM and QL muscles combined with exercise therapy had good effects in PFP.
Brandon C. Morgan et al.
Int J Sports Phys Ther. 2019 Jul; 14(4): 637–654.
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This is a large case series done on 24 patients who were diagnosed with subacromial pain syndrome (SAPS). All patients were carefully selected based on inclusion and exclusion criteria. Patients who tested positive for 3 or more tests (Hawkins-Kennedy, Neer, Painful arc, empty can and pain with resisted external rotation) with pain over anterior or anterolateral shoulder region were diagnosed as SAPS. All patients were also assessed for shoulder range of motion, manual muscle testing, and muscle palpation. Based on the examination the affected shoulder girdle muscles were treated by dry needling. For the first two visits, all the patients were treated only by dry needling without introducing any exercise program. This is deliberately done to check the specific and immediate effects of dry needling alone. Outcomes measured were Quick DASH, numerical pain rating scale (NPRS), Global rating of change (GROC) and active range of motion (AROM) of the shoulder. 21 of 24 patients reported improvement at 3rd visit and 19 of 22 reported improvement at 3-month follow-up. The result recommends usage of dry needling as an adjunct to exercise for treating SAPS.
Fernández-de-Las-Peñas C1,2, Nijs J3,4.
J Pain Res. 2019 Jun 18; 12:1899-1911
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This is a review article on current perspectives of trigger point dry needling and discusses adding pain neuroscience along with dry needling treatment. The study discusses the role of trigger point in causing pain and the mechanism of trigger point dry needling. The mechanism by which needling exerts its therapeutic effects are not fully understood and probably needling has its effects on all three levels (Peripheral, Spinal, and Supraspinal- Brain). Since all chronic pain has a biopsychosocial contribution, the author states that even central factors must be considered. Therefore, the current review proposes the usage of dry needling with pain neuroscience education, graded exercise, and manual therapy. Additionally, patient's expectations, beliefs, previous experiences and patient-clinician interaction should be considered when integrating trigger point dry needling into a comprehensive treatment approach. One cannot eliminate the patient’s expectations and beliefs during any treatment. So it is an added advantage of using pain science education when employing dry needling.
Ceballos-Laita L1, Jiménez-Del-Barrio S
Musculoskelet Sci Pract. 2019 Oct; 43:76-82
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This is the first study to investigate the short-term effects of Dry Needling (DN) in patients with hip osteoarthritis (OA). It is done as a double-blinded randomized placebo-controlled trial conducted on 30 patients, who were diagnosed with grade 2 or 3 hip OA. The patients were divided into DN group and the sham group. DN group received the needling to the active MTrPs of iliopsoas, rectus femoris, tensor fascia latae, and gluteus minimus. Three sessions of dry needling were employed and the sham group received placebo needling. The outcomes measured pre and post-treatment were pain intensity, hip passive ROM and physical functions (30s chair-stand test and 20m walk test). The results revealed that DN group got decreased pain intensity, increased hip ROM, and improved physical function, whereas the sham group had increased pain and decreased ROM. The effect of DN was attributed to the modulation of several biochemical substances associated with pain, inflammation, and hypoxia. It is a well-conducted study that shows the clinical utility of using DN as a standalone treatment in hip OA. Major limitation of the study is that the long-term follow up was not done.
Mullins JF1, Nitz AJ1, Hoch MC1.
Physiother Theory Pract. 2019 Jul 16:1-10
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This study proposes a mechanistic explanation for improving sensory-motor functions for patients with chronic ankle instability (CAI). It states that the peripheral mechanoreceptor tends to get damaged after an ankle injury, thus impacting the cortex’s ability to accurately detect the joint’s location in space and enact a coordinated response. Additionally, MTrPs will be formed as a result of injury and repetitive stress, which further reduces the motor control, reaction delay, muscle strength and the overall proprioception of the ankle complex. This puts the patients into the future risk of injury. In order to treat this, dry needling is used to regulate the altered proprioception in the muscles thereby improving the neuromuscular control. Dry needling equilibration theory (DNET) states that proprioception is improved following DN in the lower extremity by changing the muscle's length-tension relationship and leveraging minor acute discomfort to improve muscle spindle afferent information via the gamma motor system. The study gives a different perspective of dry needling apart from the pain paradigm. The same mechanistic explanation can be used for other joints as well.
Vas L1, Pai R1.
Indian J Palliat Care. 2019 Jan-Mar; 25(1):93-102.
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This study investigated the myofascial contribution to post-mastectomy pain syndrome (PMPS) and it examined the effectiveness of ultrasound-guided dry needling (USGDN) along with neural intervention (NI). It is a retrospective review done on 20 consecutive patients with treatment-refractory PMPS. Most of the patients received one or the other form of neural intervention pain management in the form of a stellate ganglion block, brachial plexus block, intrathecal pump, etc. But those treatments did not help greatly in terms of disability and movements. Hence ultrasound guided dry needling was used to treat the myofascial and other painful, adherent and scar tissue. The neck, shoulder and axillary muscles were targeted and released by appropriate length needles. Since the patients were post-surgery, post-chemo and post radiotherapy, the tissues were hard and initially showed resistance to needling and slowly yielded later on. It confirms the implication of dry needling in palliative care. The study reinstated that the myofascial component plays an important role in the causation of PMPS, which is treatable by US guided dry needling. For 20% of the subjects, dry needling was done as a stand-alone treatment. Patients improved in outcomes like NPRS, DASH, Patient health questionnaire- 9(PHQ-9) and medications used. It concluded that USGDN reduced pain, disability, and opioid use.
Kütük SG1, Özkan Y2, Kütük M3, Özdaş T4.
J Craniofac Surg. 2019 Jul;30(5):1556-1559.
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Botox in temporomandibular joint (TMJ) muscles are commonly performed for pain reduction. Recent studies reveal that even trigger point dry needling was shown to improve TMJ pain. Hence this study aims to compare the effects of botox injection versus dry needling to the patients with TMJ pain. It is a prospective study done with 40 patients, who were diagnosed with myofascial pain of temporomandibular joint (TMJ). Patients were chosen based on major and minor diagnostic criteria. Muscles treated were temporalis, masseter and lateral pterygoid. Patients were randomly assigned into Botox group (20 patients) and Dry needling group (20 patients). Outcomes measured at 6 weeks follow up were Visual analog scale (VAS), crepitation (present or absent), maximum mouth opening (MMO) and functional limitation during jaw opening. Though botox and dry needling were equally effective, the result showed that dry needling was superior to botox, in terms of pain at rest and lateral excursion ranges. The mechanical disruption of contraction knots and the needle induce damage to the neuromuscular endplates might have relaxed the muscles to lead to pain reduction. Botox is expensive and impractical in some clinical settings, but dry needling is cost-effective, has fewer complications, well tolerated and can be administered multiple sessions over a period of time.
Azizian M1, Bagheri H2, Olyaei G2, Shadmehr A2, Okhovatpour MA3, et al.
J Phys Ther Sci. 2019 Apr; 31(4):295-298.
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This is the first RCT to show the effects of dry needling in the trigger finger. Surgical treatment is often successful but not without potential complications. Dry Needling is relatively safe and easy to administer in such cases. The aim of this study was to assess short term effects of dry needling on tendon-pulley architecture, pinch grip, DASH score, and pain, in patients diagnosed with trigger finger. 58 patients were randomly assigned to an experimental and control group. The experimental group received a single session of dry needling over A1 pulley and flexor tendon while the control group received no intervention. Dry needling was employed into the flexor tendon for 3 minutes at 45* angle in the metacarpophalangeal joint level. The correctness of the technique was confirmed by observing the needle movement as the patient gently flexed the needled finger. A blinded radiologist examined and found that the tendon thickness was significantly reduced in the dry needling group but not in the control group. This study results showed that a single session of Dry Needling (DN) was effective in decreasing pain, DASH score, pulley-tendon thickness and improving pinch grip power. Before surgery, all patients must be tried by dry needling treatment to see whether it helps in pain and hand function for patients with trigger finger.
Kearns G1, Fernández-De-Las-Peñas C2,3,4, Brismée JM5, Gan J6,7, Doidge J8
J Man Manip Ther. 2019 Jul;27(3):172-179
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This is a clinical commentary that explains the complexity of the patient’s problems and how one should be wary of doing dry needling in such a situation. 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. Clinicians should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dryneedling appropriateness, the technique chosen, and potential adverse responses to treatment. Patients with a cancer history, cardiovascular diseases, autoimmune conditions, and integumentary issues were discussed and explained how clinicians must assess patients accordingly and modify the technique and dosage considerations when initiating dry needling. The author recommended the clinicians to be competent in assessing the patient within the context of the medical model and weigh the risks to benefits ratio for each patient while doing dry needling.
The top 10 articles on dry needling that was published in 2019 were reviewed here. It clearly depicted the impact of dry needling in improving pain, dysfunction, and disability. There are other good studies, which we could not include in this review for brevity. Other dry needling studies were published in the various clinical conditions like stroke, parkinsonism, orofacial pain, low back pain, neck pain, tennis elbow, plantar fasciitis, CRPS, neuropathy, etc. Few studies showed the lack of effect for dry needling and few studies showed positive effects of dry needling. Given the varied clinical manifestation and psychosocial contribution, it is crucial to include the right patient in the study group.
Studies that clearly elucidate the exact pathophysiology of MTrPs and mechanism of dry needling must done in the future. More ultrasound studies are needed to compare the physical dimensions of MTrPs pre and post dry needling. Physiotherapists, who practice dry needling must be cognizant in overall patient condition and treat the patient in a holistic perspective. Dry needling is a useful, cost effective tool to relieve neuromusculoskeletal pain and dysfunction but at the same time it should be easily diligently in accordance with the patient’s condition.
Chief Physiotherapist - RMV Hospital, Bangalore
Founder President – Dry Needling Association
Director- APTER Institute, INDIA
