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Dry Needling

Dry Needling . Meghan May & Lauren Brown. Background. Janet Travell and David Simons published the first trigger point hypothesis Muscles refer pain in patterns Dr. Ma has experience with biomedical acupuncture and has done research through the NIH Dr. Ma’s courses

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Dry Needling

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  1. Dry Needling Meghan May & Lauren Brown

  2. Background • Janet Travell and David Simons published the first trigger point hypothesis • Muscles refer pain in patterns • Dr. Ma has experience with biomedical acupuncture and has done research through the NIH • Dr. Ma’s courses • 2009- American Academy of Orthopaedic Manual Physical Therapists adopted position statement that dry needling is within scope of manual physical therapy

  3. Acupuncture • Based on energy flow throughout the body • Disruptions of the natural flow lead to disease • Acupuncture restores the natural flow • The meridians are the pathways of energy

  4. Theory • Improves tissue healing and restores normal function for muscle, tendon, and myofascial pain/dysfunction • Trigger point=contraction/knots of small muscle fibre • Exact mechanisms are unknown, but a twitch must occur in order to break the pain cycle • Typically takes several treatments

  5. Theory Continued

  6. Theory- Central Sensitization • Mechanism of referred pain from myofascial trigger points (MTrPs)- Travell and Simons. • Associated with multiple chronic pain syndromes>>> NOT specific for MTrPs. • Surrounding environment active MTrPs= ↑ levels substance P (SP), CGRP, BK, 5-HT, norepinephrine, tumor necrosing factor-alpha, and interleukin-1beta. • MTrPs= consistent nociceptive input> chemicals sensitize & activate muscle nociceptors AND glial cells into dorsal horn.

  7. The influence of dry needling of the trapezius muscle on muscle blood flow and oxygenation Cagnie B, Barbe T, De Ridder E, Van Oosterwijck J, Cools A, Danneels L. • Blood flow and oxygens levels were significantly higher immediately after treatment-lasted for 15 minutes in healthy subjects • Another study cited within this one found levels to be significantly higher for up to 30 minutes post-treatment, but the needle was left in for at least 10 minutes. • Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemicals associated with pain, inflammation, and hypoxia.

  8. Reliability for research on diagnosis of myofascial trigger points-a systematic review of the literature Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. • Trigger point=irritable nodule of taut muscle that, when palpated, is tender and painful • Reported reliability was dependent on which muscle was examined • Reliability was better for tenderness, pain, and referred pain than a taut band or twitch response

  9. Lidocaine injection vs dry needling Chang-Zern Hong, MD • This study was designed to investigate the effects of injection with a local anesthetic agent or dry needling into a myofascial trigger point (TrP) • Patients treated with dry needling had postinjection (2 weeks) soreness of significantly greater intensity and longer duration than those treated with lidocaine injection • Essential to elicit LTRs during injection to obtain an immediately desirable effect.

  10. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. • Background: research has supported that dry needling decreases short term pain similar to injecting a myofascial trigger point (MTrP) with a local anesthetic agent as long as a local twitch response (LTR) was achieved. • Objective:It is suggested that by suppressing an active MTrP with dry needling, secondary MTrPs can also be suppressed • purpose is to conduct a clinical trial to support this claim

  11. Methods • Treatment of the MTrP in the infraspinatus with dry needling on one side (chosen randomly) • Shoulder IR ROM, pain, and pressure pain thresholds of MTrP in the infraspinatus, anterior deltoid, and ECRL were assessed bilaterally before and immediately after treatment

  12. Results Significantly greater increases in ROM in the treated side

  13. Results Significantly decreased pain intensity levels in treated side

  14. Results Significantly increased pain threshold in the MTrPs of all muscles on treated side

  15. Results All significant findings still held true after data was normalized; no significant difference in untreated side

  16. Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis Kietrys et al Journal of Orthopaedic & Sports Physical Therapy

  17. Kietrys et al Background • According to this article… • MTrPs= 　 • Localized areas of taut, band-like hardness + hyperalgesic zones. • Develop anywhere in body. • 　Compressed can cause local and/or referred tenderness & pain, aggravation of existing pain, motor dysfunction, and/or autonomic phenomena. • Can contribute to impaired ROM and ↑ sensitivity to stretch. • Active- spontaneous pain VS latent- pain when compressed.

  18. Kietrys et al Background Continued • According to this article… • Mechanism of Dry Needling= • Localized twitch response (LTR) interrupts motor end-plate noise. • LTR and stretching exercises relax actin-myosin bonds in tight bands. • Gate control theory. • Causes stimulation of alpha-delta nerve fibers → activating enkephalinergic inhibitory dorsal horn interneurons → causing opioid-mediated pain suppression. • Corrects levels of several chemicals in affected muscles. • Disrupts reverberatory central nervous system circuits.

  19. Kietrys et al Methods

  20. Kietrys et al Meta-analyses • Four separate meta-analyses were performed, with pain on VAS as outcome measure: • (1) dry needling compared to sham or control, immediate effects • (2) dry needling compared to sham or control, 4 weeks • (3) dry needling compared to other treatments, immediate effects • (4) dry needling compared to other treatments, approximately 4 weeks

  21. Kietrys et al Results

  22. Kietrys et al Results Continued

  23. Kietrys et al Results Continued • Meta-analysis: Dry Needling VS Sham or Control, Immediate Effects= • Overall effect size= 1.06 (95% CI : 0.05, 2.06)>>> suggesting large effect supporting dry needling. • Study with largest treatment effect used same subject’s uninvolved side as control- reported raw between-group effect size 4.0 VAS points. • Meta-analysis: Dry Needling VS Sham or Control, 4 Weeks= • 2 studies supported dry needling over sham or control at 4 weeks; both had large effect sizes (1.95 & 1.55). • Both had raw between-group effect sizes at 4 weeks that were clinically meaningful (3.6 and 3.1 VAS points).

  24. Kietrys et al Results Continued • Meta-analysis: Dry Needling VS Other Treatments, Immediate Effects= • Overall effect size= –0.64 (95% CI: –1.21, –0.06)>>> suggesting moderate effect supporting other treatment. • Meta-analysis: Dry Needling VS Other Treatments, Approximately 4 Weeks= • Overall effect size= –0.07 (95% CI: –1.39, 1.26) suggesting>>> small effect supporting other treatment, with 95% CI crossing the line of no difference>>> NO EFFECT. • 2 studies supported dry needling at 4 weeks; both had large effect sizes (2.26 and 1.48-2.15).

  25. Kietrys et al Results Continued • Studies that supported "other" treatment: only Kamanli et al reported clinically meaningful raw between-group effect sizes at 4 weeks (2.44, 3.17 VAS points supporting botulinum toxin & lidocaine injections), with large treatment effect sizes (0.83 and 1.08). • Ay et al reported large effect favoring lidocaine injection (3.30), but raw between-group effect size only 1.55 VAS points at 4 weeks.

  26. Kietrys et al Limitations

  27. Kietrys et al Limitations Continued • Use of only 1 search term (dryneedling). • Reliability of MacDermid Quality Checklist has not been well described in the literature. • High heterogeneity in each of the 4 meta-analyses we performed>>> questionable appropriateness for performing meta-analysis. • Evidence of publication bias in the asymmetrical funnel plots for dry needling VS sham or control for both immediate effects and at 4 weeks, as well as dry needling VS other treatments for immediate effects.

  28. Unique Study • Mayoral del Moral study: • 40 subjects scheduled for TKRs. • Examined for trigger points + randomly assigned: • Intervention group- dry needling after anesthesiology, but before surgery. • Control group- NO dry needling. • All patients anesthetized= true blinding to group allocation & intervention. • Dry needled reported significantly ↓ pain levels & fewer analgesics following surgery.

  29. Summary of Dry Needling Research • 1 study on inflammatory factors on rabbits. • Poor reliability of exact location of trigger points. • Affects satellite MTrPs pain threshold and, increases ROM, decreases pain intensity. • Mechanical stimulation, local microtrauma, central sensitization & gate theory may explain it. • Produces significant changes in VAS ratings over control and “other treatments” immediately post-intervention.

  30. Current Controversy • Unclear whether a LTR must occur. • Inconsistent theories. • High heterogeneity in current published research. • Lack of research examining long-term effects.

  31. References Acupuncture, Medicinenet. 2013. Retrieved from http://www.medicinenet.com/ acupuncture/article.htm Cagnie, B., Barbe, T., De Ridder, E., Van Oosterwijck, J., Cools, A., & Danneels, L. (2012). The influence of dry needling of the trapezius muscle on muscle blood flow and oxygenation. Journal of Manipulative and Physiological Therapeutics, Vol 35, 685-695. Cagnie, B., Dewitte, V., Barbe, T., Timmermans, F., Delrue, N., & Meeus, M. (2013). Physiologic Effects of Dry Needling. Curr Pain Headache Rep, Vol 17, 348-356. Cummings, T., & White, A. (2001). Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review. Arch Phys Med Rehabil, Vol 82, 986-992. Dommerholt, J. (2011). Dry needling- peripheral and central considerations. Journal of Manual and Manipulative Therapy, Vol 19, No 4, 223-237. Dry Needling Course. 2010. Retrieved from http://dryneedlingcourse.com/

  32. References Hong, C. Z. (1994). Lidocaine Injection versus dry needling to myofascial trigger point: the importance of the local twitch response, American Journal of Physical Medicine and Rehabilitation, Vol 73, 256-263. Hsieh, Y.L., Chou, L.W., Joe, Y.S., & Hong, C.Z. (2011). Spinal Cord Mechanism Involving the Remote Effects of Dry Needling on the Irritability of Myofascial Trigger Spots in Needling on the Irritability of Myofascial Trigger Spots in Rabbit Skeletal Muscle. Arch Phys Med Rehabil, Vol 92, 1098-1105. Hsieh, Y. L., Kao, M. J., Kuan, T. S., Chen, S. M., Chen, J. T., & Hong, C. Z. (2007). Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. American Journal of Physical Medicine and Rehabilitation, Vol 86, 397-403. Kietrys, D. M., Palombaro, K. M., Azzaretto, E., Hubler, R., Schaller, B., Schlussel, J. M., & Tucker, M. (2013). Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, Vol 43, No 9, 620-634. Lucas, N., Macaskill, P., Irwig, L., Moran, R., & Bogduk, N. (2008). Reliability for research on diagnosis of myofascial trigger points-a systematic review of the literature. Clinical Journal of Pain, Vol 25, 80-89.

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