Probable mechanisms of needling therapies for myofascial pain control

Dry Needling in Sports and Sport Recovery: A Systematic Review with an Evidence Gap Map

BACKGROUND

Dry needling is an increasingly popular technique used in sports and regenerative medicine contexts. However, there is no comprehensive overview of investigations of dry needling in sports and sport recovery.

OBJECTIVES

The objectives were to perform a systematic review of dry needling in sports athletes with an evidence gap map, to identify current gaps in the literature, and to provide stakeholders with direction for future research.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines were followed. Studies on healthy and injured athletes receiving dry needling were included. Three databases (PubMed, Scopus, and Web of Science) were searched, data were synthesized narratively, key data were summarized quantitatively, and an evidence gap map was created.

RESULTS

The authors incorporated 24 studies into the current study, encompassing 580 athletes, predominantly involving talent/developmental and highly trained/national-level athletes across 13 sports. Most studies used passive or placebo controls, with 37.5% incorporating active controls. Interventions focused mainly on the lower limbs (58.3%). Around 69% of studies reported pain perception outcomes, while six examined muscular strength, activity, and range of motion. While results varied, dry needling generally showed a more positive effect on pain than on athletic performance.

CONCLUSIONS

Dry needling studies seem to describe general effectiveness and safety for reducing pain and muscle stiffness in a wide variety of body regions. However, further research is needed on underrepresented populations such as elite, world-class, and Paralympic athletes, as well as expanding investigations into long-term effects and a broader range of muscle groups, particularly the hamstrings. The results may be valuable for medical professionals, sports medicine specialists, and researchers.

REGISTRATION

OSF project no.: osf.io osf.io/h3yeq.

Dry needling in multiple sclerosis: a scoping review

OBJECTIVE

Dry needling (DN) has recently been investigated as an alternative strategy to reduce muscle spasticity and improve mobility in people with multiple sclerosis (pwMS). The aim of the present review was to identify any available literature on the potential benefits of DN in pwMS.

METHODS

A systematic literature search was conducted in the PubMed, Scopus, ScienceDirect, Embase/Ovid, CINAHL, CENTRAL, Web of Science and PEDro databases and at ClinicalTrials.gov. The search results were limited to studies published between 2000 and 2023 without language restrictions. All articles reporting on the application of DN (defined as the use of a needle to target myofascial trigger point(s) without injection) in pwMS were included. Studies related to traditional medicine were excluded. Two reviewers independently investigated the quality of reporting based on Joanna Briggs Institute critical appraisal tools. Data on the effects of DN on muscle spasticity, pain intensity, mobility and other reported outcomes in pwMS were extracted and analyzed.

RESULTS

Four original articles (two case reports and two case series) and one conference paper reporting the findings of a randomized controlled trial randomized controlled trial (RCT) were included. The RCT was small (n = 16 participants) and sham-controlled with no significant differences between groups. In all four case reports/series, reduced spasticity was observed following DN treatment in pwMS. Findings with respect to other outcomes (including pain intensity, mobility, quality of life, manual dexterity and disability reduction) were mixed.

CONCLUSION

Although no firm conclusions can be drawn from these uncontrolled case reports/series, DN for pwMS appears feasible and (based on limited clinical observation) may have potential as an adjunct therapeutic method to address spasticity in pwMS. However, the quantity and quality of available data are extremely limited. There is a need for high-quality studies of DN (ideally adequately sized RCTs with a low risk of bias) to further explore its effectiveness in the MS population.

Exploring the efficacy of acupuncture for tension-type headache: a literature review and insights from traditional Chinese medicine

Tension-type headache (TTH) is a common primary headache disorder, and recent research has focused on various treatment options. However, studies evaluating acupuncture for TTH from the perspective of Traditional Chinese Medicine (TCM) and its mechanisms are limited. This literature review synthesizes findings from twelve clinical studies that investigated acupuncture for TTH treatment. Data analysis was conducted for acupoint selection, types of acupuncture, treatment duration and needle retention time in these studies considering TCM principles. Our results indicate that acupuncture practitioners should select acupoints based on TCM syndrome differentiation and patient-specific factors. The optimal treatment duration is at least four weeks, with each session lasting a minimum of 20 minutes, and 30 minutes per session is recommended for enhanced efficacy. Additionally, the therapeutic effects of acupuncture on TTH may involve mechanisms such as the inhibition of myofascial trigger points and the modulation of central sensitization.

Dry needling for orofacial pain: a systematic review and meta-analysis of randomized clinical trials

Orofacial pain (OFP) is an ache in the front part of the head and typically has musculoskeletal, dental, neural, or sinogenic origin. Dry needling (DN) is the insertion of a solid sterile fine needle through the skin aimed at deactivating the myofascial trigger points has extensively been studied in randomized clinical trials (RCTs). This systematic review was aimed at evaluating the evidence base for the effectiveness of DN for OFP. We searched Medline, Cochrane Central, and Web of Science (from their respective inceptions to February 2024) for RCTs evaluating the effectiveness of DN in patients with OFP. Studies with individuals suffering from cervicogenic or tension type headaches as well as observational studies were excluded. Primary outcomes were pain intensity and severity; secondary outcomes were disability, quality of life, and adverse effects. The review adhered to the methods described by in the Cochrane Handbook. Twenty-four RCTs with a total of 1,318 patients suffering from OFP were included. Most had an unclear or high risk of bias, and the quality of the evidence ranged from very low to low for all comparisons and outcomes. A meta-analysis suggested that, compared with usual care alone, DN + usual care had no effect on pain intensity (visual analogue scale) (standardized mean difference = -1.89, 95% confidence intervals -5.81 to 2.02, very low certainty evidence) at follow-ups of up to 6 weeks. There is little reliable evidence for the effectiveness of DN in reducing OFP. Future, larger, more rigorous studies might reduce the existing uncertainties.

Testing the Safety of Piriformis Dry Needling Interventions: An Observational Study Evaluating the Predictive Value of Anthropometric and Demographic Factors

Objectives: The dry needling of the piriformis muscle (especially in the medial region) is a challenging procedure since there is a high risk of accidentally puncturing the sciatic nerve. This study aimed to explain the variance of the deep limit of the piriformis based on anthropometric and demographic predictors potentially associated with it by exploring if clinicians can select the optimal needle length needed accurately to avoid accidental punctures of the sciatic nerve during palpation-guided dry needling interventions. Methods: An observational study was conducted that included fifty-six patients with piriformis muscle syndrome. We recorded the skin-to-sciatic nerve distance at the location with greatest risk of accidental sciatic puncture (assessed with ultrasound imaging) and demographic (e.g., age, gender, height, weight and body mass index-BMI) and anthropometric (hip circumference) variables. Results: Thirty-four males (n = 34) and twenty-two females (n = 22) were analyzed. Although men presented a significantly greater hip circumference than women (p = 0.007), no skin-to-sciatic nerve distance differences were observed (p > 0.05). Correlation analyses revealed that the sciatic nerve's depth is associated with weight, BMI and hip perimeter (all, p < 0.01) but not with age or height (p > 0.05). Due to shared variance and multicollinearity, the hip circumference was the only predictor included in the regression model, explaining 37.9% of the piriformis muscle's deeper fascia depth variance (R2 Adjusted = 0.379). Conclusions: Although the use of landmarks and measuring the hip perimeter may result in greater dry needling accuracy and a lower risk of adverse events derived from accidental sciatic nerve puncture, ultrasound guidance is encouraged as is the safest method for avoiding serious adverse events.

Therapeutic Effects of Dry Needling on Lateral Epicondylitis: An Updated Systematic Review and Meta-analysis

OBJECTIVE

To investigate the therapeutic effects of dry needling on lateral epicondylitis and identify a relatively more effective needling technique.

DATA SOURCES

English databases (Pubmed, Web of Science, Scopus, EBSCO, ScienceDirect, Taylor & Francis, ProQuest, Cochrane, Ovid, and Embase) and Chinese databases (China National Knowledge Infrastructure, Wanfang, and VIP) were searched.

STUDY SELECTION

This study included randomized controlled trials for comparing the effectiveness of dry needling with other treatment methods for lateral epicondylitis. The primary outcome measures were pain intensity and elbow disability, while the secondary outcome measures included grip strength and upper limb function.

DATA EXTRACTION

Data extraction was performed by 2 researchers who used the Cochrane risk of bias analysis tool and the Physiotherapy Evidence Database checklist to assess the risk of bias and methodological quality of the included studies. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the quality of evidence.

DATA SYNTHESIS

A total of 17 studies that involved 979 subjects were included in this research. Dry needling exhibited a significant advantage in improving pain intensity among patients with lateral epicondylitis within 1 week after treatment (mean difference [MD]=-0.95, 95% confidence interval [CI], -1.88 to -0.02). Within 1 week and in the follow-ups that exceeded 1 week, dry needling also demonstrated better improvement in elbow disability (<1 week: standardized mean difference [SMD]=-1.37, 95% CI, -1.88 to -0.86; ≥1 week: SMD=-1.32, 95% CI, -2.23 to -0.4) and grip strength (<1 week: SMD=0.27, 95% CI, 0.01 to 0.53; ≥1 week: SMD=0.45, 95% CI, 0.02 to 0.88). Trigger point dry needling with local twitch response exhibited more significant improvement in pain intensity within 1 week (MD=-1.09, 95% CI, -1.75 to -0.44).

CONCLUSIONS

Dry needling demonstrates good therapeutic effects on pain intensity (within 1 week), function, and grip strength among patients with lateral epicondylitis. Local twitch response is necessary in treatment that targets trigger points.

A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short-term outcomes of pain and disability

BACKGROUND

The evidence supporting the application of pain neuroscience education (PNE) in patients with chronic low back pain (LBP) remains some arguments.

OBJECTIVE

This review aims to investigate the effect of PNE alone and combined with physical therapy or exercise for chronic LBP.

METHODS

PubMed, Embase, Web of Science, and the Cochrane databases were searched from establishment to June 3, 2023. Randomized controlled trials (RCT) evaluating the effect of PNE in patients with chronic LBP were considered eligible. Data were analyzed using a random-effects model (I2 >50%) or a fixed-effects model (I2 <50%) and trials were appraised using the Cochrane ROB tool. Meta-regression was conducted to assess the moderator factors.

RESULTS

Seventeen studies (1078 participants) were included in this review. PNE plus exercise and PNE plus physiotherapy both showed a reduction of short-term pain (mean differences [MD] -1.14 [-1.55, -0.72]; MD -1.15 [-1.67, -0.64]) and disability (standardized mean difference [SMD] -0.80 [-1.13, -0.47]; SMD -0.85 [-1.29, -0.40]) than physiotherapy or exercise alone. Meta-regression showed that only single PNE session duration was associated with a greater reduction in pain (P < .05). Subgroup results showed that a single PNE session exceeding 60 minutes (MD -2.04), 4 to 8 sessions (MD -1.34), intervention for 7 to 12 weeks (MD -1.32), and a group-based approach (MD -1.76) may be more beneficial.

CONCLUSION

This review indicates that adding PNE to treatment programs would lead to more efficacious effects for chronic LBP. Additionally, we preliminarily extracted dose-effect relationships for PNE intervention, providing guidance for clinicians to design effective PNE sessions.

The Effects of Dry-Needling Therapy on the Quality of Life in Athletes with Myofascial Pain Syndrome: Repeated Measures Design Study

Background: This study aims to investigate the effects of dry-needling treatment on the quality of life in athletes with myofascial pain syndrome (MPS). Methods: The participants included in the study were 50 athletes (38 males and 12 females) diagnosed with MPS. The treatments were carried out in four sessions, 5/7 days apart on 55 muscles in total. A 36-item health survey (SF-36) was implemented to determine the participants' quality of life. The chi-square test was used to determine the differences between measurements. Results: Dry-needling treatment has a positive influence on self-perspective of physical functioning (p = 0.011, on average), physical problems (p = 0.001, on average), emotional problems (p = 0.004, on average), social functioning (p = 0.001, on average), pain (p = 0.001, on average), and mental health and vitality (p = 0.001, on average) in athletes with MPS. The only quality-of-life dimension not influenced by the dry-needling treatment is the general health perception (p = 0.340, on average). Conclusions: Dry-needling therapy has positive effects on the perception of quality of life in athletes with MPS.

A survey study for the dental students' satisfaction with the "needling therapies for temporomandibular disorders" lectures

Background/purpose

Dry needling therapy and acupuncture can effectively relieve myofascial pain in temporomandibular disorders (TMDs). This study evaluated dental students' satisfaction with the "needling therapies for TMDs" lectures given in 2022 and 2023.

Materials and methods

The "needling therapies for TMDs" lectures included mainly a dry needling therapy lecture and an acupuncture lecture which were given to the fifth-year dental students in both 2022 and 2023. An additional needling therapy demonstration lecture was given in 2023 only. Immediately after the lectures, the students were asked to complete an online-based questionnaire with four survey questions regarding their satisfaction with (1) the dry needling therapy, (2) the acupuncture, (3) the overall, and (4) the needling therapy demonstration lectures using 5-point Likert scale ratings.

Results

Fifty-three (80 %) of 66 and 60 (81 %) of 74 students answered the questions in 2022 and 2023, respectively. The satisfaction rates improved from 70 % in 2022 to 83 % in 2023 for the dry needling therapy lecture, from 64 % in 2022 to 85 % in 2023 for the acupuncture lecture, and from 70 % in 2022 to 88 % in 2023 for the overall lecture. The satisfaction rate was 88 % in 2023 for the needling therapy demonstration lecture.

Conclusion

The results of this study suggest that inclusion of the needling therapy demonstration lecture in 2023 can results in a marked increase in the satisfaction rates for the lectures. The relatively-lower satisfaction rate for the acupuncture lecture in 2022 may be due to the difficulty in understanding the mechanisms underlying the acupuncture therapy.

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 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.

Effects of Dry Needling on Active Myofascial Trigger Points and Pain Intensity in Tension-Type Headache: A Randomized Controlled Study

Tension-type headache is the most prevalent type of headache and is commonly associated with myofascial pain syndrome and the presence of active myofascial trigger points. This randomized controlled trial aimed to assess the impact of dry needling on the total number of active trigger points, pain intensity, and perceived clinical change in tension-type headache subjects. Thirty-two subjects were randomly assigned to the control and dry needling groups. The presence of active trigger points in 15 head and neck muscles, the headache intensity, and the perceived clinical change were evaluated. A single dry needling technique was administered at each active trigger point across three sessions. Significant differences were observed in the post-treatment measures favouring the dry needling group, including reductions in the headache intensity scores (p = 0.034) and the total number of active trigger points (p = 0.039). Moreover, significant differences in the perception of clinical change were found between the control and treatment groups (p = 0.000). Dry needling demonstrated positive effects in reducing the number of active trigger points and improving the short-term headache intensity in tension-type headache patients. A single dry needling session applied in the cranio-cervical area resulted in a self-perceived improvement compared to the control subjects.

Effect of Mirror Therapy on Post-Needling Pain Following Deep Dry Needling of Myofascial Trigger Point in Lateral Elbow Pain: Prospective Controlled Pilot Trial

Background: This prospective randomized, controlled pilot trial to explore the immediate effect of adding Mirror Visual Feedback Therapy on pain sensitivity and motor performance among subjects suffering from post-needling pain diagnosed as Lateral Elbow Pain. Methods: A total of 49 participants (23 female, 26 male) were enrolled and randomly allocated to either the experimental group, which received Deep Dry Needling in the m. Brachioradialis, Ischemic Compression, Cold Spray, Stretching, and Mirror Visual Feedback Therapy (n = 25), or a control group without Mirror Visual Feedback Therapy (n = 24). Pre- and post-treatment evaluations included assessments of post-needling pain intensity, pressure pain threshold, two-point discrimination threshold, and maximum hand grip strength. Results: Intergroup analysis revealed a statistically significant reduction in post-needling pain intensity favoring the experimental group (U = 188.00, p = 0.034). Additionally, intragroup analysis showed significant improvements in post-needling pain intensity (MD = 0.400, SEM = 0.271, W = 137.00, p = 0.047) and pressure pain threshold (MD = 0.148 Kg/cm2, SEM = 0.038, W = 262.00, p < 0.001) within the experimental group following the intervention. Conclusions: These findings suggest a potential benefit of integrating Mirror Visual Feedback Therapy into treatment protocols for individuals with Lateral Elbow Pain experiencing post-needling discomfort. Further research is necessary to fully elucidate the clinical implications of these findings.

Effect of Korean Medicine Treatment on Patients with Postherpetic Neuralgia: A Retrospective Chart Review

Evidence regarding Korean medicine treatment (KMT) for neuropathic pain is lacking. We aimed to identify the effects of integrative KMT in patients with postherpetic neuralgia (PHN). We retrospectively analyzed the electronic medical records of patients with PHN who received KMT at Kyung Hee University Korean Medicine Hospital between August 2021 and July 2022. We evaluated the effects of KMT-comprising acupuncture, pharmacopuncture, herbal medicine, cupping, and moxibustion-on pain intensity using the numerical rating scale (NRS), Short-Form McGill Pain Questionnaire (SF-MPQ), Hospital Anxiety and Depression Scale-Anxiety (HADS-A), Hospital Anxiety and Depression Scale-Depression (HADS-D), Daily Sleep Interference Scale (DSIS), Fatigue Severity Scale (FSS), and EuroQol-5D. Among 53 patients with PHN, 13 were included. The NRS score for worst pain over 1 week decreased from 6.54 ± 0.64 at baseline to 3.85 ± 0.63 at 8 weeks (41% reduction, p < 0.01), while that for average pain over 1 week decreased from 4.93 ± 0.67 at baseline to 3.08 ± 0.46 at 8 weeks (37% reduction, p < 0.01). From baseline to 8 weeks, there were significant reductions in the SF-MPQ, HADS-A, FSS, and EuroQol-5D scores. No adverse events were reported after KMT. Therefore, KMT may be an effective treatment option for patients with PHN.

Exploring the chemical diversity of phytopathogenic fungi infecting edible fruits

Two fungi, Fusarium guttiforme and Colletotrichum horii, were cultured under different conditions to obtain fourteen compounds. The axenic cultures of F. guttiforme and C. horii in potato dextrose broth (PDB) medium yielded fusaric acid (1), 9,10-dehydrofusaric acid (2), and tyrosol, whereas their co-cultivation produced fusarinol (5), a fusaric acid complex with magnesium (3), 9,10-dehydrofusaric acid complex with magnesium (4), and 5-butyl-5-(hydroxymethyl) dihydrofuranone (9). Upon changing the medium from PDB to Czapek, different compounds (uracil, p-hydroxy acetophenone, and cyclo(L-Leu-L-Pro) were obtained. Fusaric acid (1) was biotransformed into fusarinol (5) by C. horii, suggesting a detoxification process, and three other compounds were obtained: 7-hydroxyfusarinol (7), 9,10-dehydrofusarinol (6), and fusarinyl acetate (8). Epigenetic modulation of suberohydroxamic acid against F. guttiforme afforded gibepyrone B (10). These compounds were subjected to a papain inhibition enzymatic assay; the highest inhibitory activity was displayed by the two magnesium complexes, at 56 and 54% inhibition, respectively.

Effectiveness of different percutaneous electrolysis protocols in the endogenous modulation of pain: A Double-Blinded Randomized Clinical Trial

OBJECTIVE

This randomized clinical trial investigated if the application of percutaneous electrolysis (PE) enhances endogenous pain mechanisms (EPM) when compared with a simple needle application (acting as sham).

METHODS

Forty-six asymptomatic subjects, aged 18-40 years, were randomized into three groups receiving a single ultrasound-guided PE intervention consisting of a needle insertion on the lateral epicondyle: sham (without electrical current), low-intensity (0.3 mA, 90s), or high-intensity (three pulses of 3 mA, 3s) PE. Widespread pressure pain thresholds (PPT), conditioned pain modulation (CPM), and temporal summation (TS) were bilaterally assessed in the lateral epicondyle, bicipital groove, transverse process of C5 and tibialis anterior muscle. Outcomes were obtained by an assessor blinded to the treatment allocation of the subjects.

RESULTS

No significant changes in CPM were observed in either group (omnibus ANOVA all, P > .05). A significant bilateral increase in PPT in the lateral epicondyle in the high intensity group as compared with the sham group was observed (P < .01). A significant decrease of TS in both low (P = .002) and high (P = .049) intensity groups on the right, but not on the left, tibialis anterior was also observed when compared with the sham group.

CONCLUSIONS

One session of PE is able to slightly stimulate modulatory pathways related to nociceptive gain, particularly pressure pain sensitivity and temporal summation but not conditioning pain modulation, when compared with a sham needle intervention, with changes even contralaterally. No significant differences were found between low- and high-intensity doses of percutaneous electrolysis.

No Evidence of Short-term Changes in Muscle Activity Elicited by Dry Needling in Chronic Unilateral Shoulder Pain Patients

OBJECTIVE

The aim of the study was to assess short-term changes in shoulder muscle activity elicited by dry needling in chronic unilateral shoulder pain (USP) patients.

METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted, in which 30 volunteers with USP were recruited and randomly assigned to either real or sham dry needling conditions. Pain intensity scores, pressure pain threshold, glenohumeral internal rotation angles, and electromyographic activity during isotonic shoulder tasks (shoulder flexion and extension) were assessed before, immediately, and 72 hours after the intervention in the infraspinatus and deltoid muscles.

RESULTS

A single application of real dry needling resulted in lower pain intensity scores and a larger range in glenohumeral internal rotation 72 hours after the intervention in comparison with sham dry needling. No differences in pressure pain threshold or muscle activity were observed due to the intervention.

DISCUSSION

A single application of real dry needling resulted in clinically significant changes in the short term. No differences were detected in muscle activation in the infraspinatus or deltoid muscles. Complementary interventions and longer follow-up times may be required to observe changes in muscle activity.

Bibliometric and Visual Analysis in the Field of Dry Needling for Myofascial Pain Syndrome from 2000 to 2022

Background

Evidence has shown that dry needling (DN) is effective for myofascial pain syndrome (MPS). However, bibliometrics has rarely been used to analyze the literature related to DN for MPS. The purpose of this study is to provide a systematic overview of global frontiers and research hotspots of DN in the treatment of MPS from 2000 to 2022.

Methods

A search was conducted on Web of Science Core Collection (WoS CC) for literature on DN for MPS from 2000 to 2022. Based on the basic information provided by WoS CC, CiteSpace software was used to conduct bibliometric analysis of the countries, institutions, categories, journals, authors, references and keywords involved in this topic.

Results

A total of 458 papers were obtained, with the number of publications increasing over time. Journal of Bodywork and Movement Therapies (31) was the most productive journal based on the number of publications, while Arch Phys Med Rehab (329) was the most co-cited journal. The most productive countries and institutions were USA (112) and Universidad Rey Juan Carlos (39), respectively. Fernandez-de-las-penas, Cesar has the highest number of publications (24) and Simons DG, who was an author with the highest number of citations (250). The article published by Gattie et al (co-citations: 65), and Mejuto-Vazquez et al (centrality: 0.36) were the most representative and symbolic. Based on the co-cited literature and keywords, myofascial trigger point, research methods, and acupuncture were the hot research topics and trends in the field.

Conclusion

The current status and trends in clinical research of DN for MPS are revealed according to the results of this bibliometric study, which may facilitate researchers to identify hot topics and new directions for future research.

Efficacy of Fu's Subcutaneous Needling in Treating Soft Tissue Pain of Knee Osteoarthritis: A Randomized Clinical Trial

Purpose: Fu’s subcutaneous needling (FSN) is a new acupuncture technique that produces a long-lasting effect in soft-tissue injuries. In patients with degenerative knee osteoarthritis (OA), myofascial trigger points (MTrPs) are common in the lower-limb muscles. In this randomized clinical trial, we evaluated the immediate, 1-week and 2-week effectiveness of FSN therapy in the treatment of degenerative knee OA. Patients and methods: We randomly divided 32 patients with knee OA into the FSN group (mean age: 65.73 ± 6.79 years) or the transcutaneous electrical nerve stimulation (TENS) group (mean age: 62.81 ± 5.72 years). The pressure pain threshold (PPT) and tissue hardness (TH) of the muscle and tendon attachment sites, knee range of motion, and physical ability (average walking speed) were measured. The subjective pain intensity index, Western Ontario and McMaster Universities OA Index (WOMAC), and Lequesne index were used to determine the efficacy of FSN on MTrP-induced soft-tissue pain compared with that of TENS. Results: A significantly greater improvement in pain qualities in the VAS (p < 0.05) was found in the FSN group. Moreover, in muscle and tendon qualities (including PPT and TH), a significant difference in the PPT of the quadriceps muscle (p < 0.05) was also observed among the immediate treatments in the FSN group. As for the functional index questionnaire assessment, the FSN group exhibited significant improvements among the immediate, 1-week and 2-week efficacies in terms of WOMAC (p < 0.05) and Lequesne index scores (p < 0.05). Conclusion: FSN was effective in treating soft-tissue pain in degenerative knee OA in terms of alleviating pain, strengthening walking ability, and improving overall functional performance. Pain relief was the primary benefit of FSN and a significant correlation between pain relief and knee joint mobility improvement was found. Trial registration: ClinicalTrials.gov Protocol Registration and Results System (registration number: NCT04356651).

Similarities between Ashi acupoints and myofascial trigger points: Exploring the relationship between body surface treatment points

Although acupuncture points and myofascial trigger points (TPs) are based in different medical fields, the two points share important attributes. We explored the relationship between acupuncture points and TPs based on their characteristics and the results of previous studies. We outlined the relationship between acupuncture points and TPs by examining their similarities and differences. Among the acupuncture point subgroups, TPs mostly corresponded to Ashi points. Based on the common features of TPs and Ashi points, we suggest that TPs are more closely related to Ashi points than to other acupoints. However, TPs also share some features, such as pain indication and location, with classical acupuncture points (CA) and extra acupuncture points (EA), which makes it difficult to elucidate their relationship with other subgroups. Therefore, we suggest to understand the relationship of CAs, EAs, Ashi points, and TPs. In this report, we concluded that concerning muscular pain symptoms Ashi points and TPs are indistinguishable.

Effect of Dry Needling Treatment on Tibial Musculature in Combination with Neurorehabilitation Treatment in Stroke Patients: Randomized Clinical Study

(1) Background: Introducing ultrasound-guided dry needling to neurorehabilitation treatments increases the beneficial effects of therapy. The aim of this study was to compare the effects of including an ultrasound-guided dry needling session in neurorehabilitation treatment on spasticity and gait-balance quality versus neurorehabilitation treatment in subjects who had suffered a stroke. (2) Methods: A single-blind, randomized clinical trial was conducted. Thirty-six patients who had suffered a stroke in the right middle cerebral artery signed the informed consent for participation in the study. Twenty patients finally participated and were randomly assigned to the control group (neurorehabilitation treatment) or experimental group (neurorehabilitation treatment plus ultrasound-guided dry needling). Pre-treatment and post-treatment data were collected on the same day. The experimental group (n = 10) first underwent an ultrasound-guided dry needling intervention on the tibialis anterior and tibialis posterior musculature, followed by neurorehabilitation treatment; the control group (n = 10) underwent their corresponding neurorehabilitation without the invasive technique. Pre-treatment and post-treatment measurements were taken on the same day, assessing the quality of balance-gait using the "Up and Go" test and the degree of spasticity using the Modified Modified Ashworth Scale. (3) Results: The patients who received neurorehabilitation treatment plus ultrasound-guided dry needling showed a greater decrease in spasticity in the tibial musculature after the neurorehabilitation treatment session (p < 0.001), improving balance and gait (p < 0.001). (4) Conclusions: An ultrasound-guided dry needling session combined with neurorehabilitation treatment reduced spasticity and improved balance and gait in stroke patients.

Immediate Effect of Dry Needling on the Viscoelastic Properties of a Trigger Point on the Infraspinatus Muscle Measured with MyotonPRO

Purpose: This article investigates the immediate effects of a dry needling (DN) puncture on the viscoelastic properties (tone, stiffness, elasticity) of a trigger point (TP) in the infraspinatus muscle in non-traumatic chronic shoulder pain. Method: Forty-eight individuals with non-traumatic chronic shoulder pain were recruited. The presence of a TP in the infraspinatus muscle was confirmed by a standardized palpatory exam. The viscoelastic properties were measured with a MyotonPRO device at baseline (T1), immediately after DN (T2), and 30 minutes later (T3). A DN puncture was applied to the TP to obtain a local twitch response while performing the technique. Results: Analyses of variance showed significant decreases in tone ( p < 0.001) and stiffness ( p = 0.003) across time after the DN technique. Post hoc tests revealed a significant reduction in tone and stiffness from T1 to T2 ( p ≤ 0.004) and no significant changes from T2 to T3 ( p ≥ 0.10). At T3, only stiffness remained significantly lower compared to T1 ( p = 0.013). Conclusions: This study brings new insights on the immediate mechanical effect of DN on tone and stiffness of TPs. Whether these effects are associated with symptom improvement and long-term effects still needs to be verified.

Endogenous Pain Modulation in Response to a Single Session of Percutaneous Electrolysis in Healthy Population: A Double-Blinded Randomized Clinical Trial

The purpose of this double-blinded randomized controlled trial was to investigate whether percutaneous electrolysis (PE) is able to activate endogenous pain modulation and whether its effects are dependent on the dosage of the galvanic current. A total of 54 asymptomatic subjects aged 18–40 years were randomized into three groups, receiving a single ultrasound-guided PE intervention that consisted of a needle insertion on the lateral epicondyle tendon: sham (without electrical current), low-intensity (0.3 mA, 90 s), and high-intensity (three pulses of 3 mA, 3 s). Widespread pressure pain thresholds (PPT), conditioned pain modulation (CPM), and temporal summation (TS) were assessed in the elbow, shoulder, and leg before and immediately after the intervention. Both high and low intensity PE protocols produced an increase in PPT in the shoulder compared to sham (p = 0.031 and p = 0.027). The sham group presented a significant decrease in the CPM (p = 0.006), and this finding was prevented in PE groups (p = 0.043 and p = 0.025). In addition, high-intensity PE decreased TS respect to sham in the elbow (p = 0.047) and both PE groups reduced TS in the leg (p = 0.036 and p = 0.020) without significant differences compared to sham (p = 0.512). Consequently, a single PE intervention modulated pain processing in local and widespread areas, implying an endogenous pain modulation. The pain processing effect was independent of the dosage administrated.

Evaluation of the Effectiveness of Dry Needling in the Treatment of Myogenous Temporomandibular Joint Disorders

Background and Objectives: The objective of our clinical trial was to determine the effectiveness of the deep dry needling technique (DDN) (neuromuscular deprogramming) as a first step in the treatment of temporomandibular disorders. Methods and Materials: The double-blind randomized clinical trial comprised 36 patients meeting the inclusion criteria who had signed the corresponding informed consent form. The participants were randomly distributed into two groups, the Experimental group (Group E) and the Control group (Group C). Group E received bilateral DDN on the masseter muscle, while Group C received a simulation of the technique (PN). All the participants were evaluated three times: pre-needling, 10 min post-needling, and through a follow-up evaluation after 15 days. These evaluations included, among other tests: pain evaluation using the Visual Analog Scale (VAS) and bilateral muscle palpation with a pressure algometer; evaluation of the opening pattern and range of the mouth, articular sounds and dental occlusion using T-scans; and electromyography, which was used to evaluate the muscle tone of the masseter muscles, in order to control changes in mandibular position. Results: Digital control of occlusion using Tec-Scan (digital occlusion analysis) showed a significant reduction both in the time of posterior disclusion and in the time needed to reach maximum force in an MI position after needling the muscle, which demonstrated that there were variations in the static position and the trajectory of the jaw. The symmetry of the arch while opening and closing the mouth was recovered in a centric relation, with an increase in the opening range of the mouth after the procedure. Conclusions: facial pain is significantly reduced and is accompanied by a notable reduction in muscle activity after needling its trigger points.

Short-term effects of dry needling of thenar muscles in manual laborers with carpal tunnel syndrome: a pilot, randomized controlled study

STUDY DESIGN

Pilot, randomized, single-blinded controlled clinical trial.

BACKGROUND AND OBJECTIVE

Trigger point (s) (TrPs) in thenar muscles could be a cause of narrowing of carpal tunnel in manual laborers with carpal tunnel syndrome (CTS). Effects of dry needling (DN) on the treatment of muscle tension have been reported, but no research has been done on the effect of DN on thenar tight muscles on reducing CTS symptoms. The aim of this study was to assess the effect of DN of thenar muscles TrPs in the treatment of mild-to-moderate carpal tunnel syndrome.

METHODS

Thirty manual laborers with mild-to-moderate CTS and the presence of TrP(s) in thenar muscles were randomized to DN group (n = 15) and control group (waiting list) (n = 15). The DN group received 2 sessions of DN of thenar muscles TrP(s), with a 48-h interval. The control group received no treatment. Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scores were the primary outcome, while secondary outcomes included electrophysiological domains, pinch and grip strength. Outcome measures were obtained at baseline, 48 hours, and 2 weeks after treatment (follow-up). Two-way analysis of variance (2 groups × 3 times) was used to compare within- and between-group differences. Bonferroni post hoc test was used to find any significant differences in the main effect for group, time, or interaction (group time).

RESULTS

A baseline assessment revealed no intergroup differences in all evaluated parameters (P > .05). Compared to the control group, the DN group had a statistically significant improvement in pinch and grip strength, median SDL, and BCTQ score after 2 weeks (P < .05). There were no between-group differences in the assessment of motor electrophysiologic and SNCV findings (P > .05).

CONCLUSION

Dry needling of thenar TrP(s) is effective in short-term improvement of function in manual laborers with mild-to-moderate CTS.

Ultrasound Confirmation of the Multiple Loci Hypothesis of the Myofascial Trigger Point and the Diagnostic Importance of Specificity in the Elicitation of the Local Twitch Response

The literature has hypothesized that a trigger point (TrP) area consists of a hyperperfused contracture knot with smaller hypoperfused TrPs within the contracture knot. By contrast, the only published ultrasound image of a TrP has it labeled hypoechoic (i.e., hyperperfused) with no commentary regarding smaller speckles of hypoperfusion within. Furthermore, the lack of clarity in objective definition of the terms associated with the TrP (namely, the palpable “contracture knot” and smaller nonpalpable “trigger point”) has led to unnecessary communication difficulties between and among clinicians and researchers. In this case series of three muscles across two patients, by using high-definition musculoskeletal ultrasound imaging technology, we present what we believe to be the first reliable capture of palpable hypoechoic (e.g., hypoperfused) contracture knots (previously mislabeled as a hypoechoic TrP), and a visual support of the multiple loci hypothesis first proposed by Hong and Simons—the first reliable confirmation of the hyperechoic (i.e., hypoperfused) TrP within. Initially proposed by a histological study and supported by microdialysis study, this case series lends further support for the multiple loci hypothesis through visual confirmation of palpable hypoechoic contracture knots, with smaller hypoechoic TrPs “speckles” within.

Corticosteroid injection or dry needling for musculoskeletal pain and disability? A systematic review and GRADE evidence synthesis

Background

Corticosteroid injection and dry needling have been used in the treatment of musculoskeletal conditions, but it is unclear which intervention is the most effective. The purpose of this study was to compare the effects of corticosteroid injection and dry needling for musculoskeletal conditions at short-, medium-, and long-term follow-up.

Methods

Electronic databases were searched up to 31 October 2021. Two researchers independently screened titles, abstracts and full-text articles. Randomized clinical trials (RCTs) that investigated the effectiveness of dry needling compared to corticosteroid injection in patients over 18 years with a musculoskeletal condition were included in the review. The studies had to report pain and/or disability as outcome. Risk of bias was assessed by using the revised Cochrane Collaboration tool (RoB 2.0). Quality of evidence was evaluated by using the GRADE approach.

Results

Six studies were included (n = 384 participants). Four musculoskeletal conditions were investigated. There is very low-quality evidence that CSI is superior to DN for reducing heel pain (plantar fasciitis) and lateral elbow pain at short- and medium-term follow-up, but not for myofascial pain and greater trochanteric pain. There is very low-quality evidence that DN is more effective than CSI at long-term follow-up for reducing pain in people with plantar fasciitis and lateral epicondylitis. Very low-certainty evidence shows that there is no difference between DN and CSI for disability at short-term follow-up. One study showed that CSI is superior to DN at medium-term follow-up and another observed that DN is superior to CSI for reducing disability at long-term.

Conclusions

There are no differences between DN and CSI in pain or disability for myofascial pain and greater trochanteric pain syndrome. Very-low certainty evidence suggests that CSI is superior to DN at shorter follow-up periods, whereas DN seems to be more effective than CSI at longer follow-up durations for improving pain in plantar fasciitis and lateral epicondylitis. Large RCTs with higher methodological quality are needed in order to draw more incisive conclusions.

PROSPERO registration number

CRD42020148650.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00408-y.

Dry needling has lasting analgesic effect in shoulder pain: a double-blind, sham-controlled trial

Supplemental Digital Content is Available in the Text.

Dry needling has analgesic effects in shoulder pain associated with myofascial pain syndrome. The analgesic effects last for up to 1 week.

Introduction:

Myofascial pain syndrome (MPS) affects most patients with chronic shoulder pain. Dry needling (DN) is a common treatment for MPS, but its temporal pattern and sensory effects remain unknown.

Objectives:

We evaluated in a randomized, sham-controlled study the pattern of analgesic efficacy and local sensory changes of a single session of DN for MPS in patients with chronic shoulder pain.

Methods:

Patients with chronic shoulder pain were randomized into active (n = 20) or sham (n = 21) groups. A single DN was performed by a researcher blinded to group assignment and pain outcomes. Pain intensity was assessed by the numeric rating score, and sensory thresholds were evaluated with a quantitative sensory testing protocol, including the area of tactile sensory abnormalities 7 days before needling, right before, and 7 days after the intervention.

Results:

Dry needling led to significant larger pain intensity reduction (from 6.30 ± 2.05 to 2.40 ± 2.45 in the active group; P = 0.02, effect size = −1.3 (95% CI [−2.0 to −0.68]); (number necessary to treat = 2.1). Pain reduction scores were significantly different on the second day after needling and persisted so until the seventh day and were accompanied by improvement in other dimensions of pain and a decrease in the area of mechanical hyperalgesia in the active DN group alone (P < 0.05).

Conclusion:

Active trigger points DN provided analgesic effects compared with sham and decreased the area of local mechanical hyperalgesia. These findings have practical clinical implications and may provide mechanistic insights behind MPS.

Effects of Percutaneous Electrolysis on Endogenous Pain Modulation: A Randomized Controlled Trial Study Protocol

Percutaneous electrolysis consists of the application of a galvanic electrical current throughout an acupuncture needle. It has been previously hypothesized that needling procedures' neurophysiological effects may be related to endogenous pain modulation (EPM). This protocol study describes the design of a double-blind (participant, assessor) randomized controlled trial with the aim to investigate whether percutaneous electrolysis is able to enhance EPM and whether the effect is different between two applications depending on the dosage of the galvanic electrical current. Seventy-two asymptomatic subjects not reporting the presence of pain symptoms the previous 6 months before the study, aged 18-40 years, are randomized into one of four groups: a control group who does not receive any intervention, a needling group who receives a needling intervention without electrical current, a low-intensity percutaneous electrolysis group (0.3 mA × 90 s), and a high-intensity percutaneous electrolysis group (three bouts of 3 mA × 3 s). Needling intervention consists of ultrasound-guided insertion of the needle on the common extensor tendon of the lateral epicondyle. The primary outcome is conditioned pain modulation (CPM), and secondary outcomes include widespread pressure pain sensitivity (pressure pain thresholds (PPT) over the lateral epicondyle, the cervical spine, and the tibialis anterior muscle) and temporal summation (TS). We expected that percutaneous electrolysis would have a greater influence on CPM than an isolated needling procedure and no intervention. In addition, we also postulated that there might be differences in outcome measures depending on the intensity of the electrical current during the percutaneous electrolysis application. This study makes a new contribution to the field of neurophysiological effects of percutaneous electrolysis and needling interventions.

Immediate Effects of Dry Needling on the Autonomic Nervous System and Mechanical Hyperalgesia: A Randomized Controlled Trial

BACKGROUND

Dry needling (DN) is often used for the treatment of muscle pain among physiotherapists. However, little is known about the mechanisms of action by which its effects are generated. The aim of this randomized controlled trial was to determine if the use of DN in healthy subjects activates the sympathetic nervous system, thus resulting in a decrease in pain caused by stress.

METHODS

Sixty-five healthy volunteer subjects were recruited from the University of Alcala, Madrid, Spain, with an age of 27.78 (SD = 8.41) years. The participants were randomly assigned to participate in a group with deep DN in the adductor pollicis muscle or a placebo needling group. The autonomic nervous system was evaluated, in addition to local and remote mechanical hyperalgesia.

RESULTS

In a comparison of the moment at which the needling intervention was carried out with the baseline, the heart rate of the dry needling group significantly increased by 20.60% (SE = 2.88), whereas that of the placebo group increased by 5.33% (SE = 2.32) (p = 0.001, d = 1.02). The pressure pain threshold showed significant differences between both groups, being significantly higher in the needling group (adductor muscle p = 0.001; d = 0.85; anterior tibialis muscle p = 0.022, d = 0.58).

CONCLUSIONS

This work appears to indicate that dry needling produces an immediate activation in the sympathetic nervous system, improving local and distant mechanical hyperalgesia.

Neutralizing interferon-α blocks inflammation-mediated vascular injury via PI3K and AMPK in systemic lupus erythematosus

Plasmacytoid dendritic cells (pDCs) play a key role in the initiation and amplification of systemic lupus erythematosus (SLE)-associated vascular injury. In this study, we found that dsDNA induced dose- and time-dependent increase in IFN-α and Toll-like receptor 7 (TLR7), TLR9 and IRF7 expression in pDCs. Co-cultured circulating endothelial cells (ECs) with activated pDCs significantly decreased proliferation, tube formation and migration in ECs. The elevated level of cellular IFN-α increased cell adhesion, promoted cell apoptosis, induced cell senescence and arrested cells at G0/G1 phase of endothelial progenitor cells (EPCs). Additionally, the co-culture system activated MAPK and inactivated PI3K. Pristane was used to establish a in vivo SLE-like mouse model. Importantly, we showed that INF-α-neutralizing antibody (IFN-α-NA) rescued all the changes induced by IFN-α in vitro and prevented vascular injury in pristane-induced SLE model in vivo. In conclusion, we confirmed that activated pDCs promoted vascular damage and the dysfunction of ECs/EPCs via IFN-α production. IFN-α-neutralizing antibody may be a clinical implication for preventing vascular injury. PI3K signalling and AMPK signalling were associated with SLE-associated vascular functions.

Needling Interventions for Sciatica: Choosing Methods Based on Neuropathic Pain Mechanisms-A Scoping Review

Sciatica is a condition often accompanied by neuropathic pain (NP). Acupuncture and dry needling are common treatments for pain, and the current literature supports acupuncture as an effective treatment for sciatica. However, it is unknown if the mechanisms of NP are considered in the delivery of needling interventions for sciatica. Our objective was to assess the efficacy and the effectiveness of needling therapies, to identify common needling practices and to investigate if NP mechanisms are considered in the treatment of sciatica. A scoping review of the literature on needling interventions for sciatica and a review of the literature on mechanisms related to NP and needling interventions were performed. Electronic literature searches were conducted on PubMed, MEDLINE, CINAHL and Cochrane Database of Systematic Reviews from inception to August, 2020 to identify relevant papers. Reference lists of included papers were also manually screened and a related-articles search through PubMed was performed on all included articles. Mapping of the results included description of included studies, summary of results, and identification of gaps in the existing literature. Ten articles were included. All studies used acupuncture for the treatment of sciatica, no studies on dry needling were identified. Current evidence supports the efficacy and effectiveness of acupuncture for sciatica, however, no studies considered underlying NP mechanisms in the acupuncture approach for sciatica and the rationale for using acupuncture was inconsistent among trials. This review reveals that neuropathic pain mechanisms are not routinely considered in needling approaches for patients with sciatica. Studies showed acupuncture to be an effective treatment for sciatic pain, however, further research is warranted to explore if needling interventions for sciatica and NP would be more effective if NP mechanisms are considered.

Intramuscular Electrical Stimulation Combined with Therapeutic Exercises in Patients with Shoulder Adhesive Capsulitis: A Randomised Controlled Trial

Background:

Myofascial trigger points (MTrPs) precipitate the shoulder pain severity and disability in patients with shoulder adhesive capsulitis (SAC). This study aims to compare the effectiveness of intramuscular electrical stimulation (IMES) combined with therapeutic exercises versus dry needling (DN) combined with therapeutic exercises in improving the clinical outcomes in patients with SAC.

Methods and Materials:

In this randomized controlled trial, IMES (n = 45) and DN (43) groups had received respectively IMES, and DN twice weekly for three consecutive weeks. Both groups received therapeutic exercises 1520 minutes, five days in a week during the second and third week. Pain, disability, kinesiophobia, number of active and latent MTrPs, shoulder abduction and external rotation range of motion were assessed at baseline, week-1, week-2, week-3 and follow-up at 3 months. A repeated measures ANOVA performed to find out the significant differences in the clinical outcomes between the groups.

Results:

The results of repeated measures of ANOVA shows that the post intervention timelines assessment scores of VAS, DASH, shoulder abduction and external rotation ROM, number of active and latent MTrPs and kinesiophobia were significantly (p. < 0.05) improved in both groups. However, IMES group had achieved a greater improvement over DN group (p. < 0.05) on the shoulder pain severity and disability, shoulder range of motion, number of active and latent MTrPs and kinesiophobia. Despite the significant statistical differences between the groups, IMES group did not achieve the minimal clinically important differences of 1.5cm and 11-points respectively for the VAS and DASH scores. No serious adverse effects occurred during the three weeks of treatment.

Conclusion:

IMES combined with therapeutic exercises is an effective treatment to reduce the shoulder pain severity and upper limb disability by deactivating the active and latent MTrPs and improving the shoulder abduction and external rotation range of motion in patients with SAC.

Changes in Muscle Tone, Function, and Pain in the Chronic Hemiparetic Shoulder after Dry Needling Within or Outside Trigger Points in Stroke Patients: A Crossover Randomized Clinical Trial

OBJECTIVES

To investigate the effects of applying dry needling into a trigger point (TrP) or non-TrP area in people who have suffered a stroke and to investigate if the effects of dry needling are maintained at six-week follow-up.

METHODS

A controlled, repeated-measures, crossover, double-blinded randomized trial was conducted. Nineteen patients with hemiparetic shoulder pain after a stroke event were randomly assigned to receive a single multimodal treatment session combined with TrP dry needling or non-TrP dry needling. The neuro-rehabilitation session included modulatory interventions targeting the central nervous system. Spasticity (Modified Ashworth Scale), shoulder pain intensity (numerical pain rate scale, 0-10), and upper extremity function (Motor Evaluation Scale for Upper Extremity in Stroke [MESUPES], Reaching Performance Scale [RPS]) were assessed before (baseline) and one, two, three, four, five, and six weeks after the treatment session by a blinded assessor. All participants received both sessions in a randomized order where they were followed up for six weeks before receiving the opposite treatment and then followed up for another six weeks.

RESULTS

Changes in muscle tone (all P > 0.266) and upper extremity function (MESUPES: F = 0.544, P  = 0.465; RPS close task: F = 0.820, P = 0.371; RPS far task: 0.830, P  = 0.368) were similar after both interventions at all follow-up periods. The decrease in shoulder pain was higher within the TrP dry needling group as compared with the non-TrP dry needling group, particularly at two and four weeks (P  = 0.01).

CONCLUSIONS

The effect of dry needling on muscle tone (spasticity) and upper extremity function is not related to its application in or outside of a TrP area. The effect of dry needling on shoulder pain was slightly superior when applied over a TrP in poststroke people. These effects were maintained six weeks after treatment.

Comparison of the effects of instrument assisted soft tissue mobilization and dry needling on active myofascial trigger points of upper trapezius muscle

Background: Myofascial pain syndrome is one of the most common complaints in patients referring to orthopedic treatment centers. The present study aimed to examine the effects of instrument-assisted soft tissue mobilization (IASTM) and dry needling (DN) on active myofascial trigger points (AMTrP) of the upper trapezius muscle (UTM). Methods: The current study was designed as a randomized clinical trial and a total of 81 patients, aged 18-40 years, with active myofascial trigger points in the upper trapezius muscle were randomly divided into 3 groups: group 1 (n = 30) received DN treatment, group 2 (n = 26) received IASTM treatment, and group 3 (n = 25) was considered as the control group (no intervention). The numeric pain scale (NPS), pain pressure threshold (PPT), active cervical contra-lateral flexion (ACLF), neck disability index (NDI), and muscle thickness (MT), according to rehabilitative ultrasonic imaging (RUSI), were measured at baseline, immediately after the last session (session 4 in week 2), and 1 month after the last session. The statistical analysis was conducted at a 95% confidence level. The P values less than.05 were considered as statistically significant. Results: Both techniques were effective in treating active trigger point of the upper trapezius (p<0.05), but there was no significant difference between the treatment groups in terms of any of the above variables except for ACLF (p>0.05) Conclusion: Both IASTM and DN were determined to improve NPS, PPT, ROM, and NDI in participants with active trigger points in the upper trapezius, although IASTM was more effective in increasing ACLF in these patients.

Electromyographic Assessment of the Efficacy of Deep Dry Needling versus the Ischemic Compression Technique in Gastrocnemius of Medium-Distance Triathletes

Several studies have shown that gastrocnemius is frequently injured in triathletes. The causes of these injuries are similar to those that cause the appearance of the myofascial pain syndrome (MPS). The ischemic compression technique (ICT) and deep dry needling (DDN) are considered two of the main MPS treatment methods in latent myofascial trigger points (MTrPs). In this study superficial electromyographic (EMG) activity in lateral and medial gastrocnemius of triathletes with latent MTrPs was measured before and immediately after either DDN or ICT treatment. Taking into account superficial EMG activity of lateral and medial gastrocnemius, the immediate effectiveness in latent MTrPs of both DDN and ICT was compared. A total of 34 triathletes was randomly divided in two groups. The first and second groups (n = 17 in each group) underwent only one session of DDN and ICT, respectively. EMG measurement of gastrocnemius was assessed before and immediately after treatment. Statistically significant differences (p = 0.037) were shown for a reduction of superficial EMG measurements differences (%) of the experimental group (DDN) with respect to the intervention group (ICT) at a speed of 1 m/s immediately after both interventions, although not at speeds of 1.5 m/s or 2.5 m/s. A statistically significant linear regression prediction model was shown for EMG outcome measurement differences at V1 (speed of 1 m/s) which was only predicted for the treatment group (R² = 0.129; β = 8.054; F = 4.734; p = 0.037) showing a reduction of this difference under DDN treatment. DDN administration requires experience and excellent anatomical knowledge. According to our findings immediately after treatment of latent MTrPs, DDN could be advisable for triathletes who train at a speed lower than 1 m/s, while ICT could be a more advisable technique than DDN for training or competitions at speeds greater than 1.5 m/s.

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.

Evaluation of an effectiveness and safety of the electroacupuncture in the management of intractable neuropathic pain: A prospective, open-labeled, randomized, cross-over clinical trial

BACKGROUND

There is no sufficient evidence on the effectiveness of acupuncture for neuropathic pain. This protocol describes a study that aims to evaluate the effectiveness and safety of electroacupuncture combined with conventional medicine for patients with intractable neuropathic pain, when compared with conventional medicine alone.

METHODS/DESIGN

This study is a prospective, open-labeled, randomized, cross-over clinical trial. A total of 40 patients with neuropathic pain who had a numeric rating scale (NRS) score of over 4 despite receiving conventional treatment for more than 3 months will be enrolled. Participants will receive conventional treatment for neuropathic pain (treatment C) or treatment C combined with 12 additional sessions of electroacupuncture treatment (treatment A) for 6 weeks. Participants will be randomly assigned to 1 of the 2 sequence groups (AC and CA group) with a 1:1 allocation. The differences of responder in the composite efficacy outcomes, which consist of the NRS, Brief Pain Inventory-Short Form (BPI-SF) pain subscale, and global assessment at 6 weeks after randomization will be examined as the primary outcome. Secondary outcomes include differences in the NRS, the Short-Form McGill Pain Questionnaire, BPI-SF, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Medical Outcomes Study Sleep Scale, global assessment, EQ-5D, and incremental cost-effective ratio at 6 and 15 weeks after randomization. Adverse events, vital signs, and physical examinations will be recorded to evaluate safety.

DISCUSSION

The study protocol for this trial will provide up-to-date evidence on the effectiveness and safety of electroacupuncture for patients with intractable neuropathic pain. The results will be disseminated through a peer-reviewed journal and conference presentations.

TRIAL REGISTRATION

Clinical Research Information Service, ID: KCT0003615. Registered on March 12, 2019. https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=13410& ltype=&rtype=.

Evaluating the Characteristics, Reporting and Methodological Quality of Systematic Reviews of Acupuncture for Low Back Pain by Using the Veritas Plot

Objective

To evaluate systematic reviews (SRs) of acupuncture for low back pain (LBP) in terms of characteristics, reporting and methodological quality using a Veritas plot and to explore factors that may be associated with methodological quality and reporting quality.

Study Design and Setting

We searched 8 electronic bibliographic databases to find all SRs, and we evaluated the SRs' quality in 6 dimensions, including publication year, design type, homogeneity, risk of publication bias, methodological quality by Assessment of Multiple Systematic Reviews (AMSTAR) 2 and reporting quality by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Excel 2010 and Adobe Illustrator CC were used to draw and optimize Veritas plots. Exploratory analysis was done using SPSS software version 23.0 to explore factors related to AMSTAR-2 and PRISMA scores. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence quality evaluation tool was used to grade all the outcome indicators in the included literature.

Results

We included 19 SRs in the analysis. Literature quality rank scores ranged from 9.67 to 17.00, with an average score of 13.18 ± 2.35. The average score of AMSTAR-2 was 7.47, and the average score of PRISMA was 18.47. Overall, the main issues were research strategies, inclusion and exclusion criteria, publication bias, and registration in PROSPERO. The results of exploratory analysis showed that duplication of literature selected and appropriate tools to assess the risk of bias were related to the AMSTAR-2 score, and the summary of evidence was related to the PRISMA score. The GRADE quality evaluation results showed mainly low quality.

Conclusion

The quality of SRs on acupuncture for low back pain should be improved, mainly by strengthening the methodological quality and reporting quality. The Veritas plot is an effective graphical evaluation method that is worth popularizing.

Rate and maintenance of improvement of myofascial pain with dry needling alone vs. dry needling with intramuscular electrical stimulation: a randomized controlled trial

STUDY DESIGN

Prospective, randomized.

OBJECTIVES

To determine the difference in rate and maintenance of improvement of pain and disability for Dry Needling (DN) compared to Dry Needling with Intramuscular Electrical Stimulation (DN/IMES), in Myofascial Pain Syndrome (MPS).

BACKGROUND

DN and neuromuscular electrical stimulation (NMES) have been shown to be efficacious in treating MPS. DN/IMES for MPS treatment has not been studied extensively, but initial results are promising.

METHODS

Forty-five subjects were randomly assigned to the DN (n = 25) or DN/IMES (n = 20) group. Both groups received six consecutive weekly treatments and completed NDI and NPRS questionnaires (week 0, 3, 6, and 12).

RESULTS

Both DN and DN/IMES groups showed significant improvement between weeks 0-6 on NDI (p = 0.008 and 0.00002, respectively) and NPRS scores (0 = 0.017 and p = 0.018, respectively). DN/IMES group showed significant within group changes on the NPRS between weeks 0-3 (p = 0.029). No changes were noted in the DN or DN/IMES groups between week 6-12 on NDI (p = 0.497 and p = 0.714, respectively) or NPRS (p = 0.801 and p = 0.164, respectively).

CONCLUSION

DN and DN/IMES demonstrated improvement and maintenance in disability and pain for 6 weeks. No differences in improvement of disability or pain existed between the groups at week 6 or 12.

Acupuncture for pain relief of women undergoing transvaginal oocyte retrieval: A meta analysis and systematic review protocol

BACKGROUND

Pain during oocyte retrieval, which can make the in-vitro fertilization process an unpleasant experience, is becoming a common problem. Although there are many analgesic methods available in the clinical setting, they are not therapeutically equivalent, and some are associated with varying adverse reactions. In recent years, acupuncture analgesia has been used in the perioperative period of oocyte retrieval because of its perceived efficacy and safety. The purpose of this systematic review and meta-analysis is to provide evidence that acupuncture is effective in the treatment of vaginal oocyte retrieval pain.

METHODS

Electronic searches of the following six databases will be conducted by two qualified reviewers: MEDLINE, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Medicine database, VIP database and Wanfang database. Three clinical trial registries will also be searched: World Health Organization International Clinical Trial Registry Platform, Chinese Clinical Trial Registry, Cochrane Central Register of Controlled Trials and ClinicalTrials.Gov. All searches will cover the period from inception of the database/registry to March 2020 and will be limited to publications in English and Chinese. Data identification, data selection, data extraction, and bias risk assessment will be conducted independently by3ν two or more qualified reviewers, including those who selected the studies. Visual analogue scale scores will be calculated as the primary outcome. Secondary outcomes will include results of other subjective pain rating scales, including Likert scales or other defined numerical or non-numerical scales, self-assessed by patients before, during, and after oocyte retrieval. We will use STATA software (Version 16) to perform meta-analyses, and the Grading of Recommendations, Assessment, Development and Evaluations framework to grade the quality of evidence. If quantitative analysis is not available, a systematic narrative synthesis will be provided.

PROSPERO REGISTRATION NUMBER

CRD42020170095.

Acupuncture and Dry Needling in the Reduction of Peripheral Acute Fatigue Induced in the Biceps Braquii: Protocol for a Single-blinded Randomized Controlled Clinical Trial

The present study aims to propose a protocol to verify the efficacy and acute effects of traditional Chinese acupuncture, dry needling, and the rest in peripheral acute fatigue (PAF) induced by intermittent isometric contractions of the nondominant biceps brachii (BB) of nonphysically active men in a randomized, single-blind clinical trial assessed with surface electromyography, contraction time in seconds, infrared thermal imaging, and visual analog scale applied to the PAF. These instruments will evaluate the median frequency, endurance time, temperature (°C), and perceived fatigue in BB of the volunteers. The measurements will be collected in four moments (Test 0, 01, 02, and 03) divided between the beginning and the end of two sets of exercises (Exercises 01 and 02) of intermittent isometric contractions. TRIAL IDENTIFIER: NCT03448120 in www.clinicaltrials.gov.

Myofascial pain syndrome and trigger points: evaluation and treatment in patients with musculoskeletal pain

PURPOSE OF REVIEW

Myofascial pain syndrome is a chronic pain condition characterized by the presence of myofascial trigger point, a hyperirritable painful spot involving a limited number of muscle fibers. The literature suggest that myofascial trigger points should be considered peripheral pain generators and this critical review will summarize recent findings concerning the clinical evaluation and the treatment of myofascial trigger points.

RECENT FINDINGS

The clinical features of myofascial trigger points and their contribution to the patient pain and disability have been detailed in several recent studies, which support the clinical relevance of the condition. Recent studies reported that manual palpation to identify MTrPs has good reliability, although some limitations are intrinsic to the diagnostic criteria. During the last decade, a plethora of treatments have been proposed and positive effects on pain and function demonstrated.

SUMMARY

The myofascial trigger point phenomenon has good face validity and is clinically relevant. Clinicians are encouraged to consider the contribution of myofascial trigger points to the patient's pain and disability through a careful medical history and a specific manual examination. Patients with myofascial trigger points will benefit from a multimodal treatment plan including dry needling and manual therapy techniques. Internal and external validity of research within the field must be improved.

Short-term effects of two deep dry needling techniques on pressure pain thresholds and electromyographic amplitude of the lumbosacral multifidus in patients with low back pain - a randomized clinical trial

Objectives: The purpose of this study was to compare the effects of deep dry needling (DN) with and without needle manipulation on pressure pain thresholds (PPTs) and electromyographic (EMG) amplitude of the lumbosacral multifidus (LM) in adults with low back pain (LBP). Methods: Participants were randomized into two treatment groups: with needle manipulation (n = 21) and without needle manipulation (n = 21). All participants received a single session of the assigned DN intervention. PPTs and EMG amplitude of the LM muscle were collected three times: before DN, immediately after DN, and one week after DN. Results: The needle manipulation group had a significantly greater increase in PPT immediately after the intervention and at the one-week follow-up as compared to the no needle manipulation group. The increase of PPT in the needle manipulation group was significant immediately after the intervention, and the increase remained significant at the one-week follow-up. However, there was no significant difference in EMG amplitude of the LM muscle between groups across the three time points. Discussion: Deep DN with needle manipulation appeared to reduce mechanical pressure sensitivity more than DN without manipulation for patients with LBP. Although a single session of DN could reduce pressure pain sensitivity, it may not be sufficient to improve LM muscle function. Level of Evidence: 1b. Trial registration numbers: NCT03970486.

Feasibility of Ultrasound-Guided Trigger Point Injection in Patients with Myofascial Pain Syndrome

We compared the feasibility of ultrasound (US)-guided myofascial trigger point (MTrP) injection with that of a blind injection technique following the use of shear wave elastography (SWE) for the measurement of stiffness at the MTrPs in patients with trapezius myofascial pain syndrome (MPS). A total of 41 patients (n = 41) were randomized to either the trial group (n = 21, SWE combined with US-guided injection) or the control group (n = 20, SWE combined with blind injection). At baseline and four weeks, they were evaluated for the manual muscle test (MMT), the range of motion (ROM), pain visual analogue scale (VAS) scores, Shoulder Pain and Disability Index (SPADI) scores and Neck Disability Index (NDI) scores during the abduction, adduction, flexion, extension, external rotation and internal rotation of the shoulder joint. Differences in changes in pain VAS scores, NDI scores and SPADI scores at four weeks from baseline between the two groups reached statistical significance (p = 0.003, 0.012, and 0.018, respectively). US-guided MTrP injection is a more useful modality as compared with a blind injection in patients with MPS.

Contribution of Chinese and French ear acupuncture for the management of chronic back pain: A randomised controlled trial

AIMS AND OBJECTIVES

To compare the efficacy of Chinese and French ear acupuncture in people with chronic back pain.

BACKGROUND

Chronic back pain is a common public health problem worldwide. An intervention for this condition is ear acupuncture. Several approaches are used for ear acupuncture, particularly the Chinese and French guidelines.

METHODS

An open, randomised and controlled clinical trial, followed the recommendations of the CONSORT Checklist. One hundred and eleven people were selected and randomised into three groups: Chinese ear acupuncture, French ear acupuncture and Control. Evaluations were performed before the first intervention session (initial), 1 week after the fifth session (final) and after a fifteen-day follow-up period (follow-up), using the Brief Pain Inventory, Rolland Morris Disability Questionnaire, and a thermal imaging camera. For data analysis, the Generalized Estimating Equation Model was applied, with significance level set at 5%.

RESULTS

Pain severity was significantly decreased by Chinese ear acupuncture throughout intervention period. Both types of ear acupuncture affected pain interference with daily activities. However, in the comparison between initial and final evaluations, only Chinese ear acupuncture produced statistically significant results. A reduction in physical disability was observed in both ear acupuncture-treated groups during the intervention period and, although Chinese ear acupuncture failed to induce significant changes in tissular temperature at individual time points, a significant increase in cutaneous temperature was detected after the follow-up period in the dorsal region of individuals treated with Chinese ear acupuncture. Importantly, at this time point, the mean difference between Chinese and French ear acupuncture revealed a more benefic effect of Chinese procedure on this parameter.

CONCLUSIONS

The individualised treatment based on the Chinese precepts showed, in an overall evaluation, better results for management of chronic back pain in the present study.

RELEVANCE TO CLINICAL PRACTICE

Ear acupuncture can be implemented in the nurse's clinical practice to assist the treatment of people with chronic back pain.

Trigger point dry needling for the treatment of myofascial pain syndrome: current perspectives within a pain neuroscience paradigm

Myofascial pain syndrome is a pain condition characterized by the presence of trigger points. Current evidence, mostly experimental studies, clearly supports a role of trigger points on peripheral and central sensitization since they are able to contribute to sensitization of peripheral nociceptors, spinal dorsal horn neurons, and the brainstem. Several interventions are proposed for treating trigger points, dry needling being one of the most commonly used by clinicians. There is no consensus on the clinical application of trigger point dry needling: some authors propose that local twitch responses should be elicited during the needling intervention to be effective, whereas others do not. The application of trigger point dry needling is able to reduce the excitability of the central nervous system by reducing peripheral nociception associated to the trigger point, by reducing dorsal horn neuron activity, and by modulating pain-related brainstem areas. However, the effects are mainly observed in the short-term, and effect sizes are moderateto small. Therefore, the current review proposes that the application of trigger point dry needling should be integrated into current pain neuroscience paradigm by combining its application 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.

Acupuncture-Analgesia-Mediated Alleviation of Central Sensitization

Pain can trigger central amplification called central sensitization, which ultimately results in hyperalgesia and/or allodynia. Many reports have showed acupuncture has an analgesic effect. We searched the related article on PubMed database and Cochrane database to discover central sensitization pathway in acupuncture analgesia. We summarized that acupuncture enhances the descending inhibitory effect and modulates the feeling of pain, thus modifying central sensitization. The possible mechanisms underlying the analgesic effects of acupuncture include segmental inhibition and the activation of the endogenous opioid, adrenergic, 5-hydroxytryptamine, and N-methyl-D-aspartic acid, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid/kainate pathways. Moreover, acupuncture can locally reduce the levels of inflammatory mediators. In clinical settings, acupuncture can be used to treat headache, neuropathic pain, low back pain, osteoarthritis, and irritable bowel syndrome. These mechanisms of acupuncture analgesia may be involved in the alleviation of central sensitization.

Localization of Muscle Edema and Changes on Muscle Contractility After Dry Needling of Latent Trigger Points in the Gastrocnemius Muscle

In this article, we aimed to describe what happens in skeletal muscle after dry needling intervention using magnetic resonance imaging (to show if there is edema) and tensiomyography (to measure contractile properties). At the same time, we describe the relationship between pain, edema, and contractility. Our results suggest that in asymptomatic patients, the application of dry needling over latent trigger points produce intra-muscular edema, an increase in muscle stiffness and an improved muscle contraction time.