Percutaneous Electrolysis in the Treatment of Lateral Epicondylalgia: A Single-Blind Randomized Controlled Trial

Effectiveness of Percutaneous Needle Electrolysis to Reduce Pain in Tendinopathies: A Systematic Review With Meta-Analysis

CONTEXT

Tendon injuries are common disorders in both workers and athletes, potentially impacting performance in both conditions. This is why the search for effective treatments is continuing.

OBJECTIVE(S)

The objective of this study was to analyze whether the ultrasound-guided percutaneous needle electrolysis technique may be considered a procedure to reduce pain caused by tendinosis.

EVIDENCE ACQUISITION

The search strategy included the PubMed, SCOPUS, CINAHL, Physiotherapy Evidence Database, SciELO, and ScienceDirect up to the date of February 25, 2024. Randomized clinical trials that assessed pain caused by tendinosis using the Visual Analog Scale and Numeric Rating Scale were included. The studies were evaluated for quality using the Cochrane Risk of Bias 2, and the evidence strength was assessed by the GRADEpro GDT.

EVIDENCE SYNTHESIS

Out of the 534 studies found, 8 were included in the review. A random-effects meta-analysis and standardized mean differences (SMD) were conducted. The ultrasound-guided percutaneous needle electrolysis proved to be effective in reducing pain caused by tendinosis in the overall outcome (SMD = -0.97; 95% CI, -1.26 to -0.68; I2 = 58%; low certainty of evidence) and in the short-term (SMD = -0.83, 95% CI, -1.29 to -0.38; I2 = 65%; low certainty of evidence), midterm (SMD = -1.28; 95% CI, -1.65 to -0.91; I2 = 0%; moderate certainty of evidence), and long-term (SMD = -0.94; 95% CI, -1.62 to -0.26; I2 = 71%; low certainty of evidence) subgroups.

CONCLUSION(S)

The application of the ultrasound-guided percutaneous needle electrolysis technique for reducing pain caused by tendinosis appears to be effective. However, due to the heterogeneity found (partially explained), more studies are needed to define the appropriate dosimetry, specific populations that may benefit more from the technique, and possible adverse events.

Adherence to exercise in lateral elbow tendinopathy, a scoping review

BACKGROUND

Understanding the true effects of exercise in the treatment of lateral elbow tendinopathy (LET) is hampered by insufficient information or a lack of standardisation in defining, measuring, reporting and analysis of exercise adherence.

OBJECTIVES

This scoping review aimed to explore both the quantity and scope of reporting of exercise adherence in published studies of participants with LET.

METHOD

Six databases were searched to identify original research studies written in English, investigating therapeutic exercise for LET. Eligible studies were first searched for terms related to exercise adherence. If provided, information on the terminology, definition, measurement, results and analysis of adherence were collated and summarised. Recommendations for standardized reporting of exercise adherence were developed.

RESULTS

104 studies were identified, of which 74 (71%) did not report adherence or related terms. Reference to exercise compliance or adherence occurred in 17 and 13 studies respectively. Adherence was most commonly defined as the frequency or percentage of exercise sessions completed compared to the recommendation and measured by self-reported diary. Few studies defined a threshold for adherence, provided comprehensive reporting of results or analysis of exercise adherence.

CONCLUSION

Reporting of exercise adherence in studies of LET was limited in both quantity and scope. Recommendations are made to improve the quality and consistency of reporting in future studies.

Structural and Functional Changes in Supraspinatus Tendinopathy through Percutaneous Electrolysis, Percutaneous Peripheral Nerve Stimulation and Eccentric Exercise Combined Therapy: A Single-Blinded Randomized Clinical Trial

Shoulder tendinopathies produce pain and reduce functionality. The aim of this randomized clinical trial was to analyze the effects of Percutaneous electrolysis (PE), Percutaneous peripheral Nerve Stimulation (PNS) and eccentric exercise (EE) on pain (NPRS), strength, electromyographic activity, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and functionality (DASH and SPADI) in individuals with supraspinatus tendinopathy. Participants (n = 50) were divided into two groups; they received 4 treatment sessions, 1 per week, of PE and PNS (n = 25) or 10 treatment sessions of TENS and US (n = 25). Both groups performed the EE program consisting of 3 sets of 10 repetitions of each of the 3 exercises, twice a day, during the 4 weeks. Follow-up was carried out at 4, 12 and 24 weeks after the start of the intervention. There are statistically significant differences in the analysis between groups (p < 0.001) in the post-treatment and follow-up measurements favorable to the PE+PNS+EE treatment on pain (NPRS), strength, supraspinatus electromyographic amplitude, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and DASH and SPADI questionnaires. The combined treatment with PE, PNS and EE is an effective option in the clinical management of tendinopathies, with positive results in the short and long term on the variables studied.

Pulsed negative pressure myofascial vacuum therapy and percutaneous electrolysis in the treatment of lateral epicondylalgia: A single-blind randomized controlled trial

BACKGROUND

Lateral Epicondylalgia (LE) represents one of the most common injuries of the upper limb. It is necessary to find effective treatments that reduce pain and increase functionality.

PURPOSE

To determine the effects of an integrated intervention of Pulsed Negative Pressure Myofascial Vacuum Therapy (VT), Percutaneous Electrolysis (PE) and eccentric exercise (EE) in the treatment of LE compared versus Manual Therapy soft tissue mobilization (MT) and Ultrasound therapy (US) and EE.

STUDY DESIGN

Single-blind randomized controlled trial.

METHODS

Forty participants, with unilateral LE, were randomly divided into two groups: VT + PE + EE group (n = 20) and MT + US + EE group (n = 20). The VT + PE + EE group received one weekly session for four weeks and a regimen of EE daily at-home, and the MT + US + EE group received 10 sessions over a period of two weeks and a regimen of EE daily at-home. Numerical pain rating scale (NPRS), range of motion (ROM) pressure pain threshold (PPT) and function (PRTEE questionnaire) were measured before treatment, at the end of treatment, and at one- and three-month follow-ups.

RESULTS

The statistically significant improvements were found post-treatment, favoring the VT + PE group in pain intensity (p < 0.001; ES = 0.408), PRTEE-S Pain (p = 0.001; ES = 0.377), PRTEE-S Specific function (p = 0.004; ES = 0.306) and PRTEE-S Total (p = 0.001; ES = 0.355). The VT + PE + EE treatment showed greater effectiveness than the MT + US + EE treatment at immediate post-treatment, as well as at the one-month and three-months follow-up.

CONCLUSIONS

VT and PE added to an EE program could be an effective treatment for pain, ROM, PPT, and function in patients with LE.

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.

BESS patient care pathway: Tennis elbow

This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.

Ultrasound-Guided Percutaneous Needle Electrolysis Combined With Therapeutic Exercise May Add Benefit in the Management of Soleus Injury in Female Soccer Players: A Pilot Study

CONTEXT

The performance of sprints during male soccer matches usually is slow medium paced, where the soleus and gastrocnemius (ankle plantar flexors) play a very important role. As in male soccer, soleus injuries should be considered in female soccer; but the scientific evidence is very limited in this case.

DESIGN

Pilot clinical trial study.

OBJECTIVE

To determine whether adding an ultrasound-guided percutaneous needle electrolysis (US-guided PNE) technique to a specific exercise program improved perceived pain at stretching and at palpation, ankle dorsiflexion range of motion, muscle fatigue, and sport performance in women soccer players with soleus injury.

METHODS

This pilot study recruited 20 female players with chronic soleus injury (type 1, characterized by hypoechoic image) who were assigned to one of 2 groups: an experimental group (exercise program + US-guided PNE; n = 10) or a control group (exercise program + sham stimulation; n = 10). Pain intensity, dorsiflexion range of motion, knee-flexion heel raise test, curve sprint test, and the global rating of change scale were analyzed at baseline and after treatment (4 wk) and there was no further follow-up.

RESULTS

Pain intensity at palpation and at stretching, dorsiflexion range of motion, and heel raise test values showed significant improvements (P < .05) between pretreatment and posttreatment for both groups, however, no significant differences were observed between groups. Curve sprint tests did not show significant differences between pretreatment and posttreatment for either group or between groups. However, the percentage of changes always revealed better values in favor of the PNE group. Both groups showed good player satisfaction with the therapies.

CONCLUSION

The application of the US-guided PNE combined with a specific exercise program may cause clinical benefits in the treatment of female soccer players with soleus injury.

Efficacy of different intensities of percutaneous electrolysis for musculoskeletal pain: A systematic review and meta-analysis

Objective

A meta-analysis of randomized controlled trials (RCTs) was conducted to determine the effect of ultrasound-guided percutaneous electrolysis (PE) alone or as an adjunct to other interventions on pain intensity generated by musculoskeletal disorders, depending on the intensity of the technique.

Data sources

PUBMED, EMBASE, Cochrane Library, Web of Science, SCOPUS, Health Medical Collection, and CINALH from inception to September 2022 were searched to identify documents.

Study selection

Publications investigating the effect of ultrasound-guided PE in musculoskeletal pain.

Data extraction

Data were extracted into predesigned data extraction and tables. Risk of bias was evaluated with the Cochrane Risk of Bias Tool (Rob 2.0). Thirteen articles met inclusion criteria.

Data analysis

Random-effects meta-analysis models were used to quantify the difference in pain between the PE and control groups.

Data synthesis

A significant reduction in pain was found in favor of low- (-1.89; 95% CI: -2.69; -1.10; p < 0.001) and high-intensity PE (-0.74; 95% CI: -1.36; -0.11; p: 0.02) compared to control group. Low-intensity PE showed significant reduction in pain in the short (-1.73; 95% CI: -3.13; -0.34; p < 0.02) and long term (-2.10; 95% CI: -2.93; -1.28; p = 0.005), with large effect sizes compared to control group. High-intensity PE only showed significant lower pain than control group in the long term (-0.92; 95% CI: -1.78; -0.07; p < 0.03), with a small effect size, but not in the short term.

Conclusion

We found small evidence suggesting that low-intensity PE could be more effective for musculoskeletal pain reduction than high-intensity PE. Nevertheless, scientific evidence on this subject is still scarce and studies comparing the two modalities are warranted.

Systematic review registration

www.crd.york.ac.uk/prospero, identifier CRD42022366935.

The use of respiratory muscle training in patients with pulmonary dysfunction, internal diseases or central nervous system disorders: a systematic review with meta-analysis

OBJECTIVE

The aim of this systematic review with meta-analysis was to evaluate the effectiveness of RMT in internal and central nervous system disorders, on pulmonary function, exercise capacity and quality of life.

METHODS

The inclusion criteria were (1) publications designed as Randomized Controlled Trial (RCT), with (2) participants being adults with pulmonary dysfunction caused by an internal disease or central nervous system disorder, (3) an intervention defined as RMT (either IMT or EMT) and (4) with the assessment of exercise capacity, respiratory function and quality of life. For the methodological quality assessment of risk of bias, likewise statistical analysis and meta-analysis the RevMan version 5.3 software and the Cochrane Risk of Bias Tool were used. Two authors independently analysed the following databases for relevant research articles: PubMed, Scopus, Cochrane Library, Web of Science, and Embase.

RESULTS

From a total of 2200 records, the systematic review includes 29 RCT with an overall sample size of 1155 patients. Results suggest that patients with internal and central nervous system disorders who underwent RMT had better quality of life and improved significantly their performance in exercise capacity and in respiratory function assessed with FVC and MIP when compared to control conditions (i.e. no intervention, sham training, placebo or conventional treatments).

CONCLUSION

Respiratory muscle training seems to be more effective than control conditions (i.e. no intervention, sham training, placebo or conventional treatment), in patients with pulmonary dysfunction due to internal and central nervous system disorders, for quality of life, exercise capacity and respiratory function assessed with MIP and FVC, but not with FEV1.

Efficacy of percutaneous needle electrolysis versus dry needling in musculoskeletal pain: A systematic review and meta-analysis

BACKGROUND

Physical therapists use dry needling (DN) and percutaneous needle electrolysis (PNE) to treat musculoskeletal pain.

OBJECTIVE

To investigate the efficacy of PNE vs. DN in the treatment of musculoskeletal pain.

METHODS

This systematic review and meta-analysis was based on the PICOS and PRISMA protocols. The PubMed, PEDro, Cochrane Library, SCOPUS, and Google Scholar databases were searched for randomized clinical trials measuring pain intensity in various musculoskeletal syndromes using PNE and DN. Pain outcome measures were the visual analog scale or the numerical pain rating scale. Risk of bias was assessed according to Cochrane guidelines and quality of evidence was reported using the Grading of Recommendations Assessment, Development, and Evaluation approach (GRADE). Standardized mean differences were calculated using random effects models.

RESULTS

The meta-analysis of the six included studies showed that the overall effect of PNE vs. DN for pain reduction was statistically significant at -0.74 (95% confidence interval [CI], -1.34 to -0.14) with a large effect size (SMD =-0.41; 95% CI, -0.75 to -0.08), albeit clinically insignificant in the short, medium, and long term. Risk of bias was generally low with moderate-level evidence due to the overall effect heterogeneity and the small sample.

CONCLUSIONS

Moderate-quality evidence showed that PNE is slightly more effective than DN in reducing pain. However, because the results were not clinically significant, we cannot recommend the application of PNE over DN. More high-quality studies comparing the two interventions are needed to draw firm conclusions.

Efficacy of percutaneous electrolysis for the treatment of tendinopathies: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of percutaneous electrolysis for the treatment of patients with tendinopathies.

DATA SOURCES

A systematic search of publications was conducted in Pubmed, Cinahl, Medline, Scopus and Web of Science.

METHODS

The Oxford 2011 Levels of Evidence and the Jadad scale were used to assess the quality of studies. The mean and standard deviation were obtained for each study group and used to calculate the effect size. The DerSimonian and Laird method was used to develop a random-effects model.

RESULTS

Of the 14 articles, four applied percutaneous electrolysis to the knee, three to the shoulder, three to the elbow, two to the hip and two to the ankle and foot. A meta-analysis on intensity of pain (evaluated with algometer and the Visual Analogue Scale) was performed on studies comparing percutaneous electrolysis with a control group, indicating that the groups treated with percutaneous electrolysis had better results (p = 0.01). Although percutaneous electrolysis did not overcome the analgesic effect achieved by corticosteroid injections.

CONCLUSIONS

The percutaneous electrolysis is effective for the treatment of tendinopathies. The combination of this technique with eccentric training has proven to be one of the most effective treatments to date for improving pain. PROSPERO Registration: CRD42021230005.

Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approach at the Distal Biceps Tendon: A Potential Treatment for Biceps Tendinopathy

Distal biceps brachii tendinopathy is a musculoskeletal pain condition-comprising chronic intrasubstance degeneration with alterations of the tendon structure-that is difficult to treat. Preliminary evidence suggests a positive effect for pain and related disability of percutaneous electrolysis treatment in patients with tendinopathy. Ultrasound is an excellent diagnostic tool to identify tendon injuries, such as tendinopathy, and to guide treatment approaches. Different approaches using ultrasound evaluation of the biceps tendon have been described. Our aim was to determine the validity and safety of a percutaneous electrolysis approach, targeting insertion of the distal tendon of biceps brachii, in both human (ultrasound-guided) and Thiel-embalmed cadaver (not ultrasound-guided) models. There were two approaches evaluated: an anterior approach with the elbow in extension and the forearm in supination and a posterior approach with the elbow in flexion and the forearm in pronation. A needle was inserted following the tendon up to its insertion into the radial tuberosity. The anterior approach, both in cadaveric study and US-guided intervention, revealed a close relationship between the distal biceps tendon and the brachial artery. The mean distance of the depth of the biceps tendon distal to the brachial artery was 0.21 ± 0.021 cm in the cadavers and 0.51 ± 0.024 cm in subjects. It was also found that the anterior approach has a potential technical difficulty due to the anatomical location of the brachial artery. With the posterior approach, it was possible to safely identify the tendon insertion and the needle approach, since no important vascular and nervous structures were visualized in the window of insertion of the needle. The clinician rated the posterior approach as low difficulty in all subjects. Current results would support a posterior approach with US guidance as a safe approach for applying the percutaneous electrolysis technique for insertional tendinopathies of the distal biceps brachii tendon. The current study did not assess the effectiveness of the proposed intervention; accordingly, future studies investigating the clinical effectiveness of the proposed intervention are needed.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approach at the Achilles Tendon as a Potential Treatment for Achilles Tendinopathy: A Pilot Study

Achilles tendon tendinopathy (AT) is a musculoskeletal condition characterized by pain in the Achilles tendon and impaired physical performance or sport activities. AT is difficult to treat, and the results are variable. Preliminary evidence suggests a positive effect for pain of percutaneous electrolysis in patients with tendinopathy. Our aim was to determine the validity and safety of a percutaneous electrolysis approach targeting the interphase between the Achilles tendon and the Kager's fat with ultrasound imaging in both healthy individuals and on a fresh cadaver model (not ultrasound guiding). A needle was inserted from the medial to the lateral side under the body of the Achilles tendon, just between the tendon and the Kager's triangle, about 5 cm from the insertion of tendon in the calcaneus in 10 healthy volunteers (ultrasound study) and 10 fresh cadaver legs. An accurate needle penetration of the interphase was observed in 100% of the approaches, in both human and cadaveric models. No neurovascular bundle of the sural nerve was pierced in any insertion. The distance from the tip of the needle to the sural nerve was 5.28 ± 0.7 mms in the cadavers and 4.95 ± 0.68 mms in the volunteer subjects, measured in both cases at a distance of 5 cm from the insertion of the Achilles tendon. The results of the current study support that percutaneous electrolysis can be safely performed at the Kager's fat-Achilles tendon interphase if it is US guided. In fact, penetration of the sural nerve was not observed in any needle approach when percutaneous needling electrolysis was performed by an experienced clinician. Future studies investigating the clinical effectiveness of the proposed intervention are needed.

In vitro bacteriological effect of tri-beveled needle electrolysis against Staphylococcus aureus

Percutaneous needle electrolysis using tri-beveled needles with a specific protocol (5 mA applied for 25 s) has demonstrated to provoke a clinical reduction of recurrent bacterial infections in mammary fistulas. However, the bactericidal effect of needle electrolysis in this pathology remains theoretical. This in vitro study evaluated the bactericidal effect of this protocol and whether it changed when introducing small variations. Staphylococcus aureus were generated in saline solution (9 Log₁₀ CFU/mL) and treated in three different experiments including the main protocol and introducing variations in needle gauge, intensity, and total dosage, respectively. After 24 h, the viable cell count showed that the protocol had an average reduction of 5 log₁₀ CFU/ml compared to the control group. While variations in needle gauge did not modify this effect, variations in current intensity or dosage did. This study demonstrated that the bacterial effect was greater by increasing either current intensity or total dosage, and it decreased with substantial reductions of these parameters.

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.

Analgesic and Functional Efficiency of High-Voltage Electrical Stimulation in Patients with Lateral Epicondylitis-A Report with a 180-Day Follow-Up

The available publications describing the beneficial effects of electrostimulation does not unequivocally confirm the clinical utility of high-voltage electrical stimulation (HVES) in the treatment of the lateral epicondylitis (LE). The aim of this study was the estimation of the effect of HVES on pain intensity and functional efficiency, both in the short and long term in patients with LE. The trial was registered by the Australian and New Zealand Clinical Trials Registry (ACTRN12621001389897). There were 58 patients allocated into two groups: the HVES group (n = 29, mean age 49.9 ± 11.0 years), treated with HVES (pulse duration: 200μs, frequency: 100 Hz, current amplitude in the range of 18-25 mA, voltage amplitude: 100 V), and the NORM group (n = 29, mean age 48.0 ± 12.6 years), who were healthy and untreated patients. The treatments were performed 5 days a week (from Monday to Friday) for two weeks. Treatment progress was measured by the visual analogue scale (VAS) for rest pain, night pain, and pain during activity; the Laitinen Pain Scale (LPS); and hand grip strength (HGS) before and after the treatment, as well as after 3, 6, 12, and 24 weeks. The reduction of pain (according to the VAS and LPS) and increase in the functional condition (according to the HGS) were observed in all HVES patients in the short- and long-term observation. Therefore, the HVES in treatment of LE was found to be effective and safe.

Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approaches at the Arcade of Frohse: A Potential Treatment for Radial Tunnel Syndrome

Entrapment of the radial nerve at the arcade of Frohse could contribute to symptoms in patients with lateral epicondylalgia or radial tunnel syndrome. Our aim was to determine the validity of applying percutaneous electrolysis, targeting the supinator muscle at the Frohse’s arcade with ultrasound imaging and in a Thiel-embalmed cadaver model (not ultrasound-guiding). Percutaneous electrolysis targeting the supinator muscle was conducted in five healthy volunteers (ultrasound study) and three Thiel-embalmed cadaver forearms. Two approaches, one with the forearm supinated and other with the forearm pronated were conducted. The needle was inserted until the tip reached the interphase of both bellies of the supinator muscle. Accurate needle penetration of the supinator muscle was observed in 100% in both US-imaging and cadaveric studies. No neurovascular bundle of the radial-nerve deep branch was pierced in any insertion. The distance from the tip of the needle to the neurovascular bundle was 15.3 ± 0.6 mm with the forearm supinated, and 11.2 ± 0.6 mm with the forearm pronated. The results of the current study support that percutaneous electrolysis can properly target the supinator muscle with either the forearm in supination or in pronation. In fact, penetration of the neurovascular bundle was not observed in any approach when percutaneous needling electrolysis was performed by an experienced clinician.

Short-term effectiveness of high- and low-intensity percutaneous electrolysis in patients with patellofemoral pain syndrome: A pilot study

BACKGROUND

Unilateral patellofemoral pain syndrome (PFPS) is the most frequently diagnosed knee condition in populations aged < 50 years old. Although the treatment of myofascial trigger points (MTrPs) is a common and effective tool for reducing pain, previous studies showed no additional benefits compared with placebo in populations with PFPS. Percutaneous electrolysis is a minimally invasive approach frequently used in musculotendinous pathologies which consists of the application of a galvanic current through dry needling (DN).

AIM

To evaluate changes in sensitivity, knee pain perception and perceived pain during the application of these three invasive techniques.

METHODS

A triple-blinded, pilot randomized controlled trial was conducted on fifteen patients with unilateral PFPS who were randomized to the high-intensity percutaneous electrolysis (HIPE) experimental group, low-intensity percutaneous electrolysis (LIPE) experimental group or DN active control group. All interventions were conducted in the most active MTrP, in the rectus femoris muscle. The HIPE group received a 660 mA galvanic current for 10 s, the LIPE group 220 mA × 30 s and the DN group received no galvanic current. The MTrP and patellar tendon pain pressure thresholds (PPTs) and subjective anterior knee pain perception (SAKPP) were assessed before, after and 7 d after the single intervention. In addition, perceived pain during the intervention was also assessed.

RESULTS

Both groups were comparable at baseline as no significant differences were found for age, height, weight, body mass index, PPTs or SAKPP. No adverse events were reported during or after the interventions. A significant decrease in SAKPP (both HIPE and LIPE, P < 0.01) and increased patellar tendon PPT (all, P < 0.001) were found, with no differences between the groups (VAS: F = 0.30; η2 = 0.05; P > 0.05; tendon PPT immediate effects: F = 0.15; η2 = 0.02; P > 0.05 and tendon PPT 7-d effects: F = 0.67; η2 = 0.10; P > 0.05). A significant PPT increase in rectus femoris MTrP was found at follow-up in both the HIPE and LIPE groups (both, P < 0.001) with no differences between the groups (immediate effects: F= 1.55; η2 = 0.20; P > 0.05 and 7-d effects: F = 0.71; η2 = 0.10; P > 0.05). Both HIPE and LIPE interventions were considered less painful compared with DN (F = 8.52; η2 = 0.587; P < 0.01).

CONCLUSION

HIPE and LIPE induce PPT changes in MTrPs and patellar tendon and improvements in SAKPP, and seem to produce less pain during the intervention compared with DN.

Effectiveness of Ultrasound-Guided Percutaneous Electrolysis for Musculoskeletal Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects of ultrasound-guided percutaneous electrolysis alone or as an adjunct to other interventions on pain and pain-related disability for musculoskeletal pain conditions.

DATABASES AND DATA TREATMENT

Search of MEDLINE database, Allied and Complementary Medicine Database, EMBASE database, Cumulative Index to Nursing & Allied Health Literature database, EBSCO database, PubMed database, Physiotherapy Evidence Database, Cochrane Library database, Scopus database, and Web of Science database. Randomized controlled trials in which at least one group received ultrasound-guided percutaneous electrolysis for treatment of musculoskeletal pain. To be eligible, studies had to include humans and collect outcomes on pain intensity and pain-related disability for musculoskeletal pain syndromes. Data were extracted by two reviewers. The risk of bias was assessed by the Cochrane Guidelines and the quality of evidence was reported using the Grading of Recommendations Assessment, Development and Evaluation approach. Standardized mean differences (SMDs) and random effects were calculated.

RESULTS

Ten studies were included. The meta-analysis found that ultrasound-guided percutaneous electrolysis reduced the mean pain intensity by -2.06 (95% confidence interval [CI], -2.69 to -1.42) and the pain intensity as assessed with a visual analog scale or a numeric pain rating scale with a large size effect (SMD = -1.15; 95% CI, -1.48 to -0.81) and also improved pain-related disability with a large size effect (SMD = 0.95; 95% CI, 0.73-1.18) as compared with comparison groups. No differences in effect sizes were found among the short-term, midterm, and long-term follow-ups. The risk of bias was generally low, but the heterogeneity of the overall result downgraded the evidence level. Trials included heterogeneous musculoskeletal pain conditions and short-term, midterm, and long-term follow-ups.

CONCLUSION

Moderate evidence suggests positive effects of ultrasound-guided percutaneous electrolysis for pain and pain-related disability in musculoskeletal pain conditions relative to a comparison group in the short term, midterm, and long term.

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.

Changes in Gene Expression Associated with Collagen Regeneration and Remodeling of Extracellular Matrix after Percutaneous Electrolysis on Collagenase-Induced Achilles Tendinopathy in an Experimental Animal Model: A Pilot Study

Percutaneous electrolysis is an emerging intervention proposed for the management of tendinopathies. Tendon pathology is characterized by a significant cell response to injury and gene expression. No study investigating changes in expression of those genes associated with collagen regeneration and remodeling of extracellular matrix has been conducted. The aim of this pilot study was to investigate gene expression changes after the application of percutaneous electrolysis on experimentally induced Achilles tendinopathy with collagenase injection in an animal model. Fifteen Sprague Dawley male rats were randomly divided into three different groups (no treatment vs. percutaneous electrolysis vs. needling). Achilles tendinopathy was experimentally induced with a single bolus of collagenase injection. Interventions consisted of 3 sessions (one per week) of percutaneous electrolysis or just needling. The rats were euthanized, and molecular expression of genes involved in tendon repair and remodeling, e.g., Cox2, Mmp2, Mmp9, Col1a1, Col3a1, Vegf and Scx, was examined at 28 days after injury. Histological tissue changes were determined with hematoxylin–eosin and safranin O analyses. The images of hematoxylin–eosin and Safranin O tissue images revealed that collagenase injection induced histological changes compatible with a tendinopathy. No further histological changes were observed after the application of percutaneous electrolysis or needling. A significant increase in molecular expression of Cox2, Mmp9 and Vegf genes was observed in Achilles tendons treated with percutaneous electrolysis to a greater extent than after just needling. The expression of Mmp2, Col1a1, Col3a1, or Scx genes also increased, but did not reach statistical significance. This animal study demonstrated that percutaneous electrolysis applied on an experimentally induced Achilles tendinopathy model could increase the expression of some genes associated with collagen regeneration and remodeling of extracellular matrix. The observed gene overexpression was higher with percutaneous electrolysis than with just needling.

Ultrasound-Guided Percutaneous Needle Electrolysis in Dancers with Chronic Soleus Injury: A Randomized Clinical Trial

Damage to intramuscular tendons is very common in sports injuries, specifically in soleus muscle injuries. This study sought to compare the effects of applying ultrasound- (US-) guided percutaneous needle electrolysis (PNE) in combination with an eccentric exercise program on pain and functionality in dancers with chronic soleus injury, located in the central tendon. Thirty dancers with injured central tendon of the soleus muscle were randomly allocated to a PNE group (n = 10), an eccentric exercise group (n = 10), or a combined group (n = 10). Pain, ankle dorsiflexion range of motion (DROM), endurance, the heel raise test, the DFOS questionnaire, and the minimal clinically important difference (MCID) were analyzed at baseline and after treatment (four weeks). Over half (52%) of the dancers had a chronic soleus muscle injury. Variables for pain, DROM, the heel rise test, ADL, technique, DFOS total, and DFOS-subjective variables showed significant differences (P < 0.05) in pretreatment and posttreatment in all groups, whereas no significant differences were observed between intervention groups. However, the combined group showed a higher percentage of changes compared to the other groups, and these dancers had greater perceived changes (MCID = 4.70 ± 1.42). The conclusion of the study was that dancers with chronic soleus injury, located in the central tendon, treated with a combination of US-guided PNE and an eccentric exercise program displayed improved outcomes compared to the application of PNE therapy or eccentric exercise alone. The US-guided PNE, combined with an eccentric exercise program, is a useful therapeutic tool for the treatment of chronic soleus injury, located in the central tendon. The trial is registered with NCT04042012.