Question by Dr. Aneet Kaur & Dr. Zala Surubhi - Does this work for everyone? Including children?
Answer - Caution is warranted with younger patients. Based on empirical evidence, DN is not recommended for children younger than 12 years of age. When treating children, DN should only be performed with parent and child’s consent. Care should be taken assuming a child understands the procedure.
Question by Dr. Vardhman Jain - Looking forward for physiology on mechanism -
Answer - The actual mechanism of effect of dry needling is still being debated. The localized twitch response that often occurs may interrupt motor end-plate noise, eliciting an analgesic effect. Eliciting a localized twitch response and stretching exercises relax the actin-myosin bonds in the tight bands. Some studies have suggested that pain relief and range-of-motion restoration are greater when a localized twitch response is elicited during dry needling. It has been suggested that the gate control theory of pain may play a role. Dry needling causes stimulation of alpha-delta nerve fibers, thus activating the enkephalinergic inhibitory dorsal horn interneurons and causing opioid-mediated pain suppression. Dry needling may correct levels of several chemicals in the affected muscles, including bradykinin, calcitonin gene-related peptide, and substance P. Needling of MTrPs is also theorized to disrupt reverberatory central nervous system circuits.
The physiological basis for DN depends upon the targeted tissue and treatment objectives. The treatment of myofascial trigger points (referred to as TrPs) has a different physiological basis than treatment of excessive muscle tension, scar tissue, fascia, and connective tissues.
Question by Dr. Syed - How can we learn Dry Needling?
Answer - There are many resource person who are running workshops on Dry Needling in India. We suggest you to learn from the instructor whose dry needling course of study meet the educational and clinical prerequisites as defined in this rule - Documented successful completion of a dry needling course of study. A solid background and education in anatomy, physiology, and pain sciences are prerequisites. The course must meet the following requirements: a. A minimum of 46 hours of face-to-face IMS/dry needling course study; online study is not considered appropriate training. b. Two years of practice as a licensed physical therapist prior to using the dry needling technique. and demonstrate a minimum of two years of dry needling practice techniques. The provider is not required to be a physical therapist. The instructors must be a Certified Instructor of DN or an Acupuncturist.
Question by Dr. Rajesh Thomas - How about the risk of neurovascular injuries?
Answer - Dry needling requires training and practice in order to develop the sensitivity to appreciate subtle changes in tissue compliance and an awareness of the structures in the vicinity of the trigger points. Most complications can be avoided by knowing the local anatomy, and by careful identification of the anatomical landmarks relevant to the muscle that is to be needled. Dry needling requires a well-developed kinesthetic awareness and visualization of the pathway the needle takes within the body. Several studies have shown that experienced physical therapists, and chiropractors can reach acceptable degrees of inter- and intrarater reliability.
Dangerous or Vulnerable Points - Trapezius (or any other point in the thorax due to the relative risk of pneumothorax. Needling in this region should be shallow and/or away from lung tissue. Neck points (lateral neck over major vessels, lateral neck over baroreceptors, over the spinal cord and over the brainstem) Orbit of the eye points Varicose veins, inflamed area, infection.
The risks are real. Need for training and safety precautions can not be over emphasized
Question by Dr. Nimisha - How long is the needle inserted for?
Answer - PTs should use DN only after obtaining the knowledge, skills, and attributes associated with safe and effective DN techniques.The PT should palpate the tissues for adhesions and movement restrictions. The needle is inserted for TrPs or adhesion, but after insertion, the needle is directed more superficially toward the adhesion or restriction. Rotating the needle facilitates mechanotransduction and eventually will lead to tissue relaxation. The needle is left in place until tissue relaxation has been achieved, at which point the needle can easily be removed. DN of fascia usually is a superficial DN technique. Once the needle has been withdrawn completely from the skin, pressure (hemostasis) can be applied directly to the skin over the needle insertion site to aid in the prevention of possible swelling or post needling soreness.
The needle is kept in place for approximately 30 seconds.
If the TrP is still sensitive, the needle is guided again into the muscle in the vicinity of the TrP and left in place for approximately 2 minutes.
Question by Dr. Varun - In case of sciatica, where we can do dry needling?
Answer - A PT has to palpate for TrP in Piriformis, gluteus, hamstring and calf. Dry Needling will be done in these muscles to ease pain in sciatica if the pain is arising because of trigger points in these muscles.
Question by Dr. Venkat - Does learning in India get recognized internationally?
Answer - Yes if below requirements are met, the conduct hours will be accounted in the credential evaluation.
The course must meet the following requirements: a. A minimum of 46 hours of face-to-face IMS/dry needling course study; online study is not considered appropriate training. b. Two years of practice as a licensed physical therapist prior to using the dry needling technique. and demonstrate a minimum of two years of dry needling practice techniques. The provider is not required to be a physical therapist. The instructors must be a Certified Instructor of DN or an Acupuncturist.
Best is difficult to tell as in India resource persons are not maintaining documentations like evaluation of workshops on ratings, testimonials, etc. Try to inquire from participants of different workshops under different resource person. That could be the only guide for trying to meet the best in practice.
Question by Dr. Vijendra - Are there any specific points?
Answer - Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation.
TrPs are hyperirritable spots within a taut band of contractured skeletal muscle fibers that produce local and/or referred pain when stimulated. TrPs are divided into active and latent TrPs dependent upon the degree of irritability. Active TrPs are spontaneously painful, while latent TrPs are only painful when stimulated, for example, with digital pressure.
Question by Dr. Surojit - Can we apply Dry Needling techniques in conditions other than TrP relief?
Answer - DN is used for treatment of excessive muscle tension, scar tissue, fascia, and connective tissues.
DN is also indicated with restrictions in range of motion due to contractured muscle fibers or taut bands, or other soft tissue restrictions, such as fascial adhesions or scar tissue. TrPs have been identified in numerous diagnoses, such as radiculopathies, joint dysfunction, disk pathology, tendonitis, craniomandibular dysfunction, migraines, tension-type headaches, carpal tunnel syndrome, computer-related disorders, whiplash associated disorders, spinal dysfunction, pelvic pain and other urologic syndromes, post-herpetic neuralgia, complex regional pain syndrome, nocturnal cramps, phantom pain, and other relatively uncommon diagnoses such as Barré Liéou syndrome, or neurogenic pruritus, among others.
Question by Dr. Priyank - Is it legal for a Physio in India to go invasive?
Answer - In 2009, the American Academy of Orthopaedic Manual Physical Therapists adopted a position statement that dry needling is within the scope of manual physical therapy. Licensed physical therapists can use dry needling under the scope of their practice on if they are certified to the guidelines explained earlier. Dry needling also falls within the scope of acupuncture practice. Physical therapists are not licensed acupuncturists and do not practice acupuncture.
Present Physiotherapy curriculum in India provides education anatomy, physiology, and pain. But Dry Needling isn’t covered in the syllabus.
At national front of India there is no authority to discipline any practitioner who performs the task or skill incorrectly or might likely harm a patient. Patients can complain to Consumer Protection Act for negligence or malpractice.
Question by Dr. Dhrashti - How much sitting required for complete recovery?
Answer - Typically, it may take one to several visits for a positive reaction to take place. Here the effort is to cause mechanical and biochemical changes without any pharmacological means using Dry Needling.
Question by Dr. Deepak - Certified Taping by American and Europe? Is the certification valid in India? Is there any licence exam to make it valid in India?
There is no governance to check the validity of our own profession in India. Expecting validation of certificates from abroad is too much to expect from Indian Government. Like India, anyone can start a society or a trust and run an institute or academy in abroad too. Some are well governed and authentic. In such cases their certificates are more valid than ours. In India there is criteria to differentiate a Learner & Instructor. Sad fact or happy fact? In India anyone who gets certified for a technique or a course, starts instructor course. Even if not certified one can run a course. So No difference.
Question by Dr. Varun - Can we perform dry needling daily or alternate days? And how many sessions needed to get result? How long does the effects of dry needling last?
Answer - Yes you can perform dry needling daily depending upon the goals. It also depends on type of responders. Depending on the responsiveness of the patient to needling, they are divided into 3 types: Strong responders Average responders Weak responders
How long does the effect lasts? Typically, it may take one to several visits for a positive reaction to take place. Here the effort is to cause mechanical and biochemical changes without any pharmacological means.
Question by Dr. Deepak - We have read many books. Indian as well as Foreign authors. How many knows about dry needling? If the therapy is 40 years old and only two systematic reviews are done, it is not less?
Answer - There are only 5-10 books which purely talks about Dry Needling. Reason - Its Modality of Choice in Treatment. We cannot rely on one technique to get desired result.
Regarding its knowledge - How many students in India knows about Myofascial Pain syndrome where dry needling is practiced most for? Yet in many states myofascial pain syndrome or work related musculoskeletal disorders are not covered in syllabus. Even if covered, the teachers who are teaching, was it covered in their syllabus?
For Research - In India, research and statistics are just part of syllabus in final year B.P.T for project submission. In most colleges the results are manipulated or direct copy pasting of other research articles is practiced. No check on the reliability or validity of such papers! Students submit dissertation only as a partial requirement to complete masters as per university rules. Our education in Physiotherapy itself is in question. How many colleges arrange a statistician or research methodology qualified teachers for imparting knowledge in bio statistics and research methodology. Cases goes unreported. Lack of documentation leads to lack of good research in practice, hence two systematic reviews. That doesn't mean a technique isn't effective. Even minimal level of evidence is an acceptable treatment approach.
Question by Dr. Nijal - Can we give DN in brachial plexus injury?
Answer - We need to understand the application of DN. Brachial plexus injury if occurred due to trauma and in the phase 1 of rehabilitation where patient might be immobilized, chances of development of trigger points are maximum due to immobility. In order to ease pain, DN could be of help. Even in later stages if it turns into chronic pain, DN has its effectiveness in lowering central sensitization too.
"Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation."
Question by Dr. Venkata Sai - Can DN be used as an adjunct during rehabilitation of neurological condition? Effectiveness? Evidences?
Answer - Yes, Low
Only one RCT compared the effect of direct MTrP dry needling with usual care (DiLorenzo et al., 2004). That study reported a significant short-term reduction in post stroke shoulder pain in patients who received MTrP needling plus standard rehabilitation compared with those who received standard rehabilitation alone (p < 0.001).
Question by Dr. Priya Raman - Can it be used in geriatric patients? (For Pediatric please check first comment)
Answer - Yes
There is no age restriction or precaution specific for dry needling and long as the patients are healthy and do not have preexisting conditions that are precautions for dry needling. It has been successfully used on patients as old as 75.
Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: a randomized controlled trial.
Salom-Moreno J, Sánchez-Mila Z, Ortega-Santiago R, Palacios-Ceña M, Truyol-Domínguez S, Fernández-de-las-Peñas C.
Abstract OBJECTIVE: The purpose of this study was to determine the effects of deep dry needling (DDN) on spasticity, pressure sensitivity, and plantar pressure in patients who have had stroke. METHODS: A randomized controlled trial was conducted. Thirty-four patients who previously had a stroke were randomly assigned either an experimental group that received a single session of DDN over the gastrocnemius and tibialis anterior muscles on the spastic leg or a control group that received no intervention. Spasticity (evaluated with the Ashworth Scale); pressure pain thresholds over the deltoid muscle, second metacarpal, and tibialis anterior muscle; and plantar pressure (baropodometry) were collected by a blinded assessor before and 10 minutes after intervention. RESULTS: A greater number of individuals receiving DDN exhibited decreased spasticity after the intervention (P < .001). The analysis of covariance showed that pressure pain thresholds increased bilaterally in patients receiving DDN compared with those who did not receive the intervention (P < .001). The analysis of covariance also found that patients receiving DDN experienced bilateral increases of support surface in the forefoot, unilateral increase of the support surface in the rear foot of the treated (affected) side, and bilateral decreases in mean pressure (all, P < .02) as compared with those who did not receive DDN. CONCLUSIONS: Our results suggest that a single session of DDN decreases spasticity and widespread pressure sensitivity in individuals with poststroke spasticity. Deep dry needling also induced changes in plantar pressure by increasing the support surface and decreasing the mean pressure.
Question by Dr. Vindhya - Sometimes patients with Vit B12, D3 and calcium deficiencies happens to face such ailments or other. For eg. Cervical Spondylitis with headache with or without radiculopathy. They often present with TrP or sharp pain at particular points like attachments of trapezius, at nape of neck or SCM muscle insertion behind ear lobe. Or say some localized pain in small joints due to overuse or stress. Whether DN at such points helps in giving temporary relief? Is DN done only over points patient complain of pain?
Answer - Yes DN will provide temporary relief if performed correctly by PT. Certain points are dangerous and you have asked about same muscles. Chances of Pneumothorax is more in case of Upper Trapezius. With SCM chances of stimulating baroreceptors are more. And at nape of neck, direct insertion in spinal cord is there. These are areas where precautionary measures should be taken. Also superficial dry needling will be choice of treatment in such cases. In case of chronic pain arising because of deficiencies, a proper differential diagnosis is must. Fibromyalgia is one such neuromusculoskeletal condition where tender points are more common. A detailed evaluation is must to check whether the patient has Fibromyalgia with associated co morbidities. This is imp coz studies shows that DN is not much effective in relieving pain of tender points of Fibromyalgia.
DN is applied mainly on the site of pain. If combination of DN and TENS is there, it would be more effective.
Answer - "Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation."
DN is used for treatment of excessive muscle tension, scar tissue, fascia, and connective tissues.
DN is also indicated with restrictions in range of motion due to contractured muscle fibers or taut bands, or other soft tissue restrictions, such as fascial adhesions or scar tissue. TrPs have been identified in numerous diagnoses, such as radiculopathies, joint dysfunction, disk pathology, tendonitis, craniomandibular dysfunction, migraines, tension-type headaches, carpal tunnel syndrome, computer-related disorders, whiplash associated disorders, spinal dysfunction, pelvic pain and other urologic syndromes, post-herpetic neuralgia, complex regional pain syndrome, nocturnal cramps, phantom pain, and other relatively uncommon diagnoses such as Barré Liéou syndrome, or neurogenic pruritus, among others.
Question by Dr. Ashiyana - Can it be used over bones or bony prominences for bone pain?
Answer - Few PTs take Bones as back stops. In case of Medial and lateral epicondyles— few PTs do needling of the bone and tendon for microtrauma
Dangerous or vulnerable points includes Trapezius. Needling in this region should be away from lung tissue as well as bone or cartilage. Over the sternum and over the infrascapular fossa should be needled superficially or obliquely due to congenital foramen in these boney structures which are evident in a percentage of population.
Question by Dr. Deepak - What is the effectiveness ratio of dry needling vs non invasive therapeutic treatment options?
Answer - The treatment options for active MTrPs: transcutaneous electrical nerve stimulation (TENS), electrical muscle stimulation (EMS), ischemic compression, myofascial release therapy, stretch with coolant spray, interferential current, stretch, ultrasound, direct dry needling, trigger point injection (with various solutions and medications), neuroreflexotherapy, deep pressure soft-tissue massage, hydrocollator superficial heat, exercise, yoga, acupuncture, ice massage, magnetic stimulation, laser therapy, botulinum toxin, topical anesthetic preparation, passive rhythmic release, active rhythmic release, counterstrain, high-velocity low-amplitude thrust, sulfur mud baths, biofeedback, and clinical psychophysiology.
Summary of Evidence for pain relief using different modalities for MPS -
* Laser Therapies - unclear evidence * Electrotherapies - TENS appears to have an immediate effect, there is limited evidence for the use of FREMS, HVGS, EMS, and IFC for MTrP pain * Ultrasound - Moderate evidence * Physical/Manual Therapies - moderate level Several studies reported that exercise and stretching appeared to be the effective therapy when included in treatment groups comparing active to placebo modalities.
Effectiveness of Trigger Point Dry Needling - The effectiveness of TrP-DN is, to some extent, dependent upon the ability to accurately palpate MTrPs. Without the required excellent palpation skills, TrP-DN can be a rather random process.
Considering the invasive nature of TrP-DN, it is very difficult to judge the effectiveness. When researchers use minimal, sham, superficial, or placebo needling, there is growing evidence that even light touch of the skin can stimulate mechanoreceptors coupled to slow conducting afferents, which causes activity in the insular region and subsequent increased feelings of well-being and decreased feelings of unpleasantness.
Question by Dr. Nimisha - Recent Evidence for Dry Needling effectiveness!
Answer -
Comparison of dry needling and physiotherapy in treatment of myofascial pain syndrome Rayegani, Seyed Mansoor; Bayat, Masume; Bahrami, Mohammad HasanView Profile; Raeissadat, Seyed Ahmad; Kargozar, Elham. Clinical Rheumatology33.6 (Jun 2014): 859-64.
Abstract
To compare the effects of dry needling and physiotherapy in treatment of myofascial pain syndrome, a randomized controlled trial was performed on 28 patients with myofascial pain syndrome (MPS) of upper trapezius muscle in the Physical Medicine and Rehabilitation Center of Shohadaye Tajrish Hospital from April 2009 to April 2010. After matching the age, sex, duration of symptoms, pain severity, and quality of life measures, subjects were randomly assigned into two subgroups of case (dry needling) and control (physiotherapy). One week and 1 month after receiving standard therapeutic modalities, outcomes and intragroup and intergroup changes in pain severity, pressure pain of trigger point (TP), and quality of life measures were evaluated and compared. After 1 month, both the physiotherapy and dry needling groups had decreased resting, night, and activity pain levels (p<0.05). Pressure pain threshold of TP and some scores of quality of life (SF-36) were improved (p<0.05). Overall results were similar in both groups. It seems that both physiotherapy modalities and dry needling have equal effect on myofascial pain of the upper trapezius muscle.
Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M.
Abstract
STUDY DESIGN:
Systematic review and meta-analysis.
BACKGROUND:
Myofascial pain syndrome (MPS) is associated with hyperalgesic zones in muscle called myofascial trigger points. When palpated, active myofascial trigger points cause local or referred symptoms, including pain. Dry needling involves inserting an acupuncture-like needle into a myofascial trigger point, with the goal of reducing pain and restoring range of motion.
OBJECTIVE:
To explore the evidence regarding the effectiveness of dry needling to reduce pain in patients with MPS of the upper quarter.
METHODS:
An electronic literature search was performed using the key word dry needling. Articles identified with the search were screened for the following inclusion criteria: human subjects, randomized controlled trial (RCT), dry needling intervention group, and MPS involving the upper quarter. The RCTs that met these criteria were assessed and scored for internal validity using the MacDermid Quality Checklist. Four separate meta-analyses were performed: (1) dry needling compared to sham or control immediately after treatment, (2) dry needling compared to sham or control at 4 weeks, (3) dry needling compared to other treatments immediately after treatment, and (4) dry needling compared to other treatments at 4 weeks.
RESULTS:
The initial search yielded 246 articles. Twelve RCTs were ultimately selected. The methodological quality scores ranged from 23 to 40 points, with a mean of 34 points (scale range, 0-48; best possible score, 48). The findings of 3 studies that compared dry needling to sham or placebo treatment provided evidence that dry needling can immediately decrease pain in patients with upper-quarter MPS, with an overall effect favoring dry needling. The findings of 2 studies that compared dry needling to sham or placebo treatment provided evidence that dry needling can decrease pain after 4 weeks in patients with upper-quarter MPS, although a wide confidence interval for the overall effect limits the impact of the effect. Findings of studies that compared dry needling to other treatments were highly heterogeneous, most likely due to variance in the comparison treatments. There was evidence from 2 studies that lidocaine injection may be more effective in reducing pain than dry needling at 4 weeks.
CONCLUSION:
Based on the best current available evidence (grade A), we recommend dry needling, compared to sham or placebo, for decreasing pain immediately after treatment and at 4 weeks in patients with upper-quarter MPS. Due to the small number of high-quality RCTs published to date, additional well-designed studies are needed to support this recommendation.
Treatment of nonspecific thoracic spine pain with trigger point dry needling and intramuscular electrical stimulation: a case series. Rock JM1, Rainey CE1.
Abstract
STUDY DESIGN:
Case Series.
BACKGROUND AND PURPOSE:
Myofascial trigger points (MTrPs) are a common occurrence in many musculoskeletal issues and have been shown to be prevalent in both subjects with nonspecific low back pain and whiplash associated disorder. Trigger point dry needling (DN) has been shown to reduce pain and improve function in areas such as the cervical and lumbar spine, shoulder, hip, and knee, but has not been investigated in the thoracic spine. The purpose of this case series was to document the use of DN with intramuscular electrical stimulation (IES) in subjects with nonspecific thoracic spine pain.
CASE DESCRIPTION:
The subjects were both active duty military males aged 31 and 27 years who self-referred to physical therapy for thoracic spinal pain. Physical examination demonstrated thoracic motor control dysfunction, tissue hypertonicity, and tenderness to palpation of bilateral thoracic paraspinal musculature in both subjects. This indicated the presence of possible MrTPs. Objective findings in the first subject included painful thoracic flexion and bilateral rotation in each of these planes of movement. Pain reduction was observed when postural demands of the spine and trunk musculature were reduced through positional changes. Patient 1 demonstrated pain with posterior to anterior (P/A) pressure at T9 to T12. The second subject had bilaterally limited and painful thoracic rotation actively with normal passive rotation and demonstrated pain with P/A pressure at T4 to T7.
INTERVENTION:
The subjects were treated with DN and IES for a total of two visits each. DN was performed to paraspinal and multifidus musculature at the levels of elicited pain with P/A testing and IES set at a frequency level of 4 (1.5Hz) for 20 minutes.
OUTCOMES:
Subject 1 reported reduced pain with standing flexion from a 62mm VAS score on initial evaluation to 26mm at his second visit. Subject 2 reported being "quite a bit better" in symptoms on the GROC following his second treatment. His VAS score reported following weightlifting activities changed from 43mm on initial evaluation to 20mm at his second visit. Both subjects also demonstrated a 10 degree improvement in active thoracic spinal rotation (on the right for Subject 1 and bilateral for Subject 2) following their second treatment.
DISCUSSION:
Both subjects demonstrated motor control dysfunctions and pain with P/A pressure in the thoracic spine. With the use of DN and IES, immediate reduction was seen in subject perceived symptoms, and pain free ROM was improved. Extended treatment and follow up was not plausible due to the high pace tempo and demands of their operational training schedule. With research indicating the influence of MTrPs on a multitude of musculoskeletal issues and the prevalence of thoracic spine pain, further research is indicated for examining the effects of DN and IES for motor control and painful conditions occurring in the thoracic spine.
A Novel Treatment Modality for Myofascial Pain Syndrome: Hyperbaric Oxygen Therapy Kiralp, Mehmet Zeki, MD; Uzun, Günalp, MD; Dinçer, Ümit, MD; Sen, Ahmet, MDView Profile; Yildiz, Senol, MD; et al. Journal of the National Medical Association101.1 (Jan 2009): 77-80.
Abstract (summary)
The aim of the present study was to evaluate the effects of hyperbaric oxygen (HBO) therapy on myofascial pain syndrome (MPS). Thirty patients with the diagnosis of MPS were divided into HBO (n=20) and control groups (n=10). Patients in the HBO group received a total of 10 HBO treatments in 2 weeks. Patients in the control group received placebo treatment in a hyperbaric chamber. Pain threshold and visual analogue scale (VAS) measurements were performed immediately before and after HBO therapy and 3 months thereafter. Additionally, Pain Disability Index (PDI) and Short Form 12 Health Survey (SF-12) evaluations were done before HBO and after 3 months. HBO therapy was well tolerated with no complications. In the HBO group, pain threshold significantly increased and VAS scores significantly decreased immediately after and 3 months after HBO therapy. PDI, Mental and Physical Health SF-12 scores improved significantly with HBO therapy after 3 months compared with pretreatment values. In the control group, pain thresholds, VAS score, and Mental Health SF-12 scores did not change with placebo treatment; however, significant improvement was observed in the Physical Health SF-12 test. We concluded that HBO therapy may be a valuable alternative to other methods in the management of MPS. Our results warrant further randomized, double-blinded and placebo-controlled studies to evaluate the possible role of HBO in the management of MPS.
A Novel Treatment Modality for Myofascial Pain Syndrome: Hyperbaric Oxygen Therapy Kiralp, Mehmet Zeki, MD; Uzun, Günalp, MD; Dinçer, Ümit, MD; Sen, Ahmet, MDView Profile; Yildiz, Senol, MD; et al. Journal of the National Medical Association101.1 (Jan 2009): 77-80.
Abstract (summary)
The aim of the present study was to evaluate the effects of hyperbaric oxygen (HBO) therapy on myofascial pain syndrome (MPS). Thirty patients with the diagnosis of MPS were divided into HBO (n=20) and control groups (n=10). Patients in the HBO group received a total of 10 HBO treatments in 2 weeks. Patients in the control group received placebo treatment in a hyperbaric chamber. Pain threshold and visual analogue scale (VAS) measurements were performed immediately before and after HBO therapy and 3 months thereafter. Additionally, Pain Disability Index (PDI) and Short Form 12 Health Survey (SF-12) evaluations were done before HBO and after 3 months. HBO therapy was well tolerated with no complications. In the HBO group, pain threshold significantly increased and VAS scores significantly decreased immediately after and 3 months after HBO therapy. PDI, Mental and Physical Health SF-12 scores improved significantly with HBO therapy after 3 months compared with pretreatment values. In the control group, pain thresholds, VAS score, and Mental Health SF-12 scores did not change with placebo treatment; however, significant improvement was observed in the Physical Health SF-12 test. We concluded that HBO therapy may be a valuable alternative to other methods in the management of MPS. Our results warrant further randomized, double-blinded and placebo-controlled studies to evaluate the possible role of HBO in the management of MPS.
Question by Dr. Farooq - Can we use any electrical modalities before or after the treatment?
Answer - Yes you can use electrical modalities but precautionary measures should be taken if hematoma or bleeding is observed, or in case of any sign of infection or inflammation is seen. Below is one example of a study with DN + Heat Therapy
Evid Based Complement Alternat Med. 2014;2014:638268. doi: 10.1155/2014/638268. Epub 2014 Oct 14. Effects of Temperature on Chronic Trapezius Myofascial Pain Syndrome during Dry Needling Therapy. Wang G, Gao Q, Hou J, Li J.
Abstract
The purpose of this study was to investigate the effects of temperature on chronic trapezius myofascial pain syndrome during dry needling therapy. Sixty patients were randomized into two groups of dry needling (DN) alone (group A) and DN combined with heat therapy group (group B). Each patient was treated once and the therapeutic effect was assessed by the visual analogue scale (VAS), pressure pain threshold (PPT), and the 36-item short form health survey (SF-36) at seven days, one month, and three months after treatment. Evaluation based on VAS and PPT showed that the pain of patients in groups A and B was significantly (P < 0.05) relieved at seven days, one month, and three months after treatment Compared to before treatment. There was significantly (P < 0.05) less pain in group B than group A at one and three months after treatment. The SF-36 evaluation demonstrated that the physical condition of patients in both groups showed significant (P < 0.05) improvement at one month and three months after treatment than before treatment. Our study suggests that both DN and DN heating therapy were effective in the treatment of trapezius MPS, and that DN heating therapy had better long-term effects than DN therapy.
Question by Dr. Ajay Joshi - Effectiveness of DN for Osteoarthritis.
Answer - Yes effective
Trigger point acupuncture for treatment of knee osteoarthritis - a preliminary RCT for a pragmatic trial Itoh, Kazunori; Hirota, Satoko; Katsumi, Yasukazu; Ochi, Hideki; Kitakoji, Hiroshi. Acupuncture in Medicine26.1 (2008): 17-26.
Abstract (summary)
There is evidence for the efficacy of acupuncture treatment in knee osteoarthritis, but it remains unclear which acupuncture modes are most effective. We evaluated the effects of trigger point acupuncture on pain and quality of life in knee osteoarthritis patients, compared with acupuncture at standard points, and sham acupuncture.
Thirty patients (27 women, 3 men; aged 61-82 years) with non-radiating knee osteoarthritis pain for at least six months and normal neurological examination were randomised to one of three groups for the study period of 21 weeks. Each group received five acupuncture treatment sessions. The standard acupuncture point group (n=10) received treatment at traditional acupuncture points for knee pain; the trigger point acupuncture group (n=10) received treatment at trigger points; and the third group (n=10) received sham acupuncture treatment at the trigger points. Outcome measures were pain intensity (visual analogue scale, VAS) and WOMAC index (Western Ontario and McMaster Universities Arthritis Index). The groups were compared by the area under the curve method.
Five patients dropped out of the study because of lack of improvement, and one patient (in the trigger point acupuncture group) dropped out because of deterioration of symptoms; the remaining 24 patients were included in the analysis. After treatment, the trigger point acupuncture group reported less pain intensity on VAS than the standard acupuncture or sham treatment group, but both the trigger point acupuncture and standard acupuncture groups reported improvement of function of knee. There was a significant reduction in pain intensity between pre-treatment and five weeks after treatment for the trigger point acupuncture (P<0.01) and standard acupuncture groups (P<0.01) included in the analysis, but not for the sham treatment group. Group comparison using the area under the curves demonstrated a significant difference only between trigger point acupuncture and sham treatment groups analysed (P<0.025 for VAS, and P<0.031 for WOMAC).
These results suggest that trigger point acupuncture therapy may be more effective for osteoarthritis of the knee in some elderly patients than standard acupuncture therapy.
Question by Dr. Vijay Bhardwaj - Can DN be used in Diabetic patients?
Answer - No Due to loss of sensation and time take to heal. Even chances of bleeding will be more in Diabetic Patients. There are no studies done on Diabetic using Dry Needling.
if anyone is looking for more Physiotherapi services 1 in 3 Women who had a baby wet themselves Incontinence could be urinary incontinence and faecal incontinence. Incontinence is the inability to control micturition resulting in the loss of urine. These dysfunctions are caused by pregnancy & childbirth,poor pelvic floor muscle function,constipation,poor fluid & toileting habits,chronic cough,obesity, strenuous sports, aging & menopause ,neurological conditions like MS and stroke Bladder Disorders / Bladder Dysfunction
Question by Dr. Aneet Kaur & Dr. Zala Surubhi - Does this work for everyone? Including children?
ReplyDeleteAnswer - Caution is warranted with younger patients. Based on empirical evidence, DN is not recommended for children younger than 12 years of age. When treating children, DN should only be performed with parent and child’s consent. Care should be taken assuming a child understands the procedure.
Question by Dr. Vardhman Jain - Looking forward for physiology on mechanism -
ReplyDeleteAnswer - The actual mechanism of effect of dry needling is still being debated. The localized twitch response that often occurs may interrupt motor end-plate noise, eliciting an analgesic effect. Eliciting a localized twitch response and stretching exercises relax the actin-myosin bonds in the tight bands. Some studies have suggested that pain relief and range-of-motion restoration are greater when a localized twitch response is elicited during dry needling. It has been suggested that the gate control theory of pain may play a role. Dry needling causes stimulation of alpha-delta nerve fibers, thus activating the enkephalinergic inhibitory dorsal horn interneurons and causing opioid-mediated pain suppression. Dry needling may correct levels of several chemicals in the affected muscles, including bradykinin, calcitonin gene-related peptide, and substance P. Needling of MTrPs is also theorized to disrupt reverberatory central nervous system circuits.
The physiological basis for DN depends upon the targeted tissue and treatment objectives. The treatment of myofascial trigger points (referred to as TrPs) has a different physiological basis than treatment of excessive muscle tension, scar tissue, fascia, and connective tissues.
DeleteQuestion by Dr. Syed - How can we learn Dry Needling?
ReplyDeleteAnswer - There are many resource person who are running workshops on Dry Needling in India. We suggest you to learn from the instructor whose dry needling course of study meet the educational and clinical prerequisites as defined in this rule -
Documented successful completion of a dry needling course of study.
A solid background and education in anatomy, physiology, and pain sciences are prerequisites.
The course must meet the following requirements:
a. A minimum of 46 hours of face-to-face IMS/dry needling course study; online study is not considered appropriate training.
b. Two years of practice as a licensed physical therapist prior to using the dry needling technique. and demonstrate a minimum of two years of dry needling practice techniques. The provider is not required to be a physical therapist.
The instructors must be a Certified Instructor of DN or an Acupuncturist.
Question by Dr. Rajesh Thomas - How about the risk of neurovascular injuries?
ReplyDeleteAnswer - Dry needling requires training and practice in order to develop the sensitivity to appreciate subtle changes in tissue compliance and an awareness of the structures in the vicinity of the trigger points. Most complications can be avoided by knowing the local anatomy, and by careful identification of the anatomical landmarks relevant to the muscle that is to be needled. Dry needling requires a well-developed kinesthetic awareness and visualization of the pathway the needle takes within the body. Several studies have shown that experienced physical therapists, and chiropractors can reach acceptable degrees of inter- and intrarater reliability.
Dangerous or Vulnerable Points -
Trapezius (or any other point in the thorax due to the relative risk of pneumothorax. Needling in this region should be shallow and/or away from lung tissue.
Neck points (lateral neck over major vessels, lateral neck over baroreceptors, over the spinal cord and over the brainstem)
Orbit of the eye points
Varicose veins, inflamed area, infection.
The risks are real. Need for training and safety precautions can not be over emphasized
Question by Dr. Nimisha - How long is the needle inserted for?
ReplyDeleteAnswer - PTs should use DN only after obtaining the knowledge, skills, and attributes associated with safe and effective DN techniques.The PT should palpate the tissues for adhesions and movement restrictions. The needle is inserted for TrPs or adhesion, but after insertion, the needle is directed more superficially toward the adhesion or restriction. Rotating the needle facilitates mechanotransduction and eventually will lead to tissue relaxation. The needle is left in place until tissue relaxation has been achieved, at which point the needle can easily be removed. DN of fascia usually is a superficial DN technique. Once the needle has been withdrawn completely from the skin, pressure (hemostasis) can be applied directly to the skin over the needle insertion site to aid in the prevention of possible swelling or post needling soreness.
The needle is kept in place for approximately 30 seconds.
If the TrP is still sensitive, the needle is guided again into the muscle in the vicinity of the TrP and left in place for approximately 2 minutes.
Question by Dr. Varun - In case of sciatica, where we can do dry needling?
ReplyDeleteAnswer - A PT has to palpate for TrP in Piriformis, gluteus, hamstring and calf. Dry Needling will be done in these muscles to ease pain in sciatica if the pain is arising because of trigger points in these muscles.
Question by Dr. Venkat - Does learning in India get recognized internationally?
ReplyDeleteAnswer - Yes if below requirements are met, the conduct hours will be accounted in the credential evaluation.
The course must meet the following requirements:
a. A minimum of 46 hours of face-to-face IMS/dry needling course study; online study is not considered appropriate training.
b. Two years of practice as a licensed physical therapist prior to using the dry needling technique. and demonstrate a minimum of two years of dry needling practice techniques. The provider is not required to be a physical therapist.
The instructors must be a Certified Instructor of DN or an Acupuncturist.
Best is difficult to tell as in India resource persons are not maintaining documentations like evaluation of workshops on ratings, testimonials, etc. Try to inquire from participants of different workshops under different resource person. That could be the only guide for trying to meet the best in practice.
DeleteQuestion by Dr. Vijendra - Are there any specific points?
ReplyDeleteAnswer - Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation.
TrPs are hyperirritable spots within a taut band of contractured skeletal muscle fibers that produce local and/or referred pain when stimulated. TrPs are divided into active and latent TrPs dependent upon the degree of irritability. Active TrPs are spontaneously painful, while latent TrPs are only painful when stimulated, for example, with digital pressure.
Question by Dr. Surojit - Can we apply Dry Needling techniques in conditions other than TrP relief?
ReplyDeleteAnswer - DN is used for treatment of excessive muscle tension, scar tissue, fascia, and connective tissues.
DN is also indicated with restrictions in range of motion due to contractured muscle fibers or taut bands, or other soft tissue restrictions, such as fascial adhesions or scar tissue. TrPs have been identified in numerous diagnoses, such as radiculopathies, joint dysfunction, disk pathology, tendonitis, craniomandibular dysfunction, migraines, tension-type headaches, carpal tunnel syndrome, computer-related disorders, whiplash associated disorders, spinal dysfunction, pelvic pain and other urologic syndromes, post-herpetic neuralgia, complex regional pain syndrome, nocturnal cramps, phantom pain, and other relatively uncommon diagnoses such as Barré Liéou syndrome, or neurogenic pruritus, among others.
Question by Dr. Priyank - Is it legal for a Physio in India to go invasive?
ReplyDeleteAnswer - In 2009, the American Academy of Orthopaedic Manual Physical Therapists adopted a position statement that dry needling is within the scope of manual physical therapy. Licensed physical therapists can use dry needling under the scope of their practice on if they are certified to the guidelines explained earlier. Dry needling also falls within the scope of acupuncture practice. Physical therapists are not licensed acupuncturists and do not practice acupuncture.
Present Physiotherapy curriculum in India provides education anatomy, physiology, and pain. But Dry Needling isn’t covered in the syllabus.
At national front of India there is no authority to discipline any practitioner who performs the task or skill incorrectly or might likely harm a patient. Patients can complain to Consumer Protection Act for negligence or malpractice.
Question by Dr. Dhrashti - How much sitting required for complete recovery?
ReplyDeleteAnswer - Typically, it may take one to several visits for a positive reaction to take place. Here the effort is to cause mechanical and biochemical changes without any pharmacological means using Dry Needling.
Question by Dr. Deepak - Certified Taping by American and Europe? Is the certification valid in India? Is there any licence exam to make it valid in India?
ReplyDeleteThere is no governance to check the validity of our own profession in India. Expecting validation of certificates from abroad is too much to expect from Indian Government. Like India, anyone can start a society or a trust and run an institute or academy in abroad too. Some are well governed and authentic. In such cases their certificates are more valid than ours. In India there is criteria to differentiate a Learner & Instructor. Sad fact or happy fact? In India anyone who gets certified for a technique or a course, starts instructor course. Even if not certified one can run a course. So No difference.
Question by Dr. Varun - Can we perform dry needling daily or alternate days? And how many sessions needed to get result? How long does the effects of dry needling last?
ReplyDeleteAnswer - Yes you can perform dry needling daily depending upon the goals. It also depends on type of responders.
Depending on the responsiveness of the patient to needling, they are divided into 3 types:
Strong responders
Average responders
Weak responders
How long does the effect lasts?
Typically, it may take one to several visits for a positive reaction to take place.
Here the effort is to cause mechanical and biochemical changes without any pharmacological means.
Question by Dr. Deepak - We have read many books. Indian as well as Foreign authors. How many knows about dry needling? If the therapy is 40 years old and only two systematic reviews are done, it is not less?
ReplyDeleteAnswer - There are only 5-10 books which purely talks about Dry Needling. Reason - Its Modality of Choice in Treatment. We cannot rely on one technique to get desired result.
Regarding its knowledge - How many students in India knows about Myofascial Pain syndrome where dry needling is practiced most for? Yet in many states myofascial pain syndrome or work related musculoskeletal disorders are not covered in syllabus. Even if covered, the teachers who are teaching, was it covered in their syllabus?
For Research - In India, research and statistics are just part of syllabus in final year B.P.T for project submission. In most colleges the results are manipulated or direct copy pasting of other research articles is practiced. No check on the reliability or validity of such papers! Students submit dissertation only as a partial requirement to complete masters as per university rules. Our education in Physiotherapy itself is in question. How many colleges arrange a statistician or research methodology qualified teachers for imparting knowledge in bio statistics and research methodology. Cases goes unreported. Lack of documentation leads to lack of good research in practice, hence two systematic reviews. That doesn't mean a technique isn't effective. Even minimal level of evidence is an acceptable treatment approach.
Question by Dr. Deepak - I have heard that DN cures Ankylosing Spondylosis?
ReplyDeleteAnswer - It cannot cure but it can help ease the pain.
Question by Dr. Nijal - Can we give DN in brachial plexus injury?
ReplyDeleteAnswer - We need to understand the application of DN. Brachial plexus injury if occurred due to trauma and in the phase 1 of rehabilitation where patient might be immobilized, chances of development of trigger points are maximum due to immobility. In order to ease pain, DN could be of help. Even in later stages if it turns into chronic pain, DN has its effectiveness in lowering central sensitization too.
"Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation."
Question by Dr. Venkata Sai - Can DN be used as an adjunct during rehabilitation of neurological condition? Effectiveness? Evidences?
ReplyDeleteAnswer - Yes, Low
Only one RCT compared the effect of direct MTrP dry needling with usual care (DiLorenzo et al., 2004). That study reported a significant short-term reduction in post stroke shoulder pain in patients who received MTrP needling plus standard rehabilitation compared with those who received standard rehabilitation alone (p < 0.001).
Question by Dr. Priya Raman - Can it be used in geriatric patients? (For Pediatric please check first comment)
ReplyDeleteAnswer - Yes
There is no age restriction or precaution specific for dry needling and long as the patients are healthy and do not have preexisting conditions that are precautions for dry needling. It has been successfully used on patients as old as 75.
Question by Dr. Vijendra - If we want to reduce spasticity, we got to work on the spine, upper extremities and/or lower extremities?
ReplyDeleteAnswer - Yes it helps in spasticity. Yet more studies need to prove its effectiveness. The author Cesar Fernandes have done many studies.
J Manipulative Physiol Ther. 2014 Oct;37(8):569-79. doi: 10.1016/j.jmpt.2014.06.003. Epub 2014 Sep 8.
Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: a randomized controlled trial.
Salom-Moreno J, Sánchez-Mila Z, Ortega-Santiago R, Palacios-Ceña M, Truyol-Domínguez S, Fernández-de-las-Peñas C.
Abstract
OBJECTIVE:
The purpose of this study was to determine the effects of deep dry needling (DDN) on spasticity, pressure sensitivity, and plantar pressure in patients who have had stroke.
METHODS:
A randomized controlled trial was conducted. Thirty-four patients who previously had a stroke were randomly assigned either an experimental group that received a single session of DDN over the gastrocnemius and tibialis anterior muscles on the spastic leg or a control group that received no intervention. Spasticity (evaluated with the Ashworth Scale); pressure pain thresholds over the deltoid muscle, second metacarpal, and tibialis anterior muscle; and plantar pressure (baropodometry) were collected by a blinded assessor before and 10 minutes after intervention.
RESULTS:
A greater number of individuals receiving DDN exhibited decreased spasticity after the intervention (P < .001). The analysis of covariance showed that pressure pain thresholds increased bilaterally in patients receiving DDN compared with those who did not receive the intervention (P < .001). The analysis of covariance also found that patients receiving DDN experienced bilateral increases of support surface in the forefoot, unilateral increase of the support surface in the rear foot of the treated (affected) side, and bilateral decreases in mean pressure (all, P < .02) as compared with those who did not receive DDN.
CONCLUSIONS:
Our results suggest that a single session of DDN decreases spasticity and widespread pressure sensitivity in individuals with poststroke spasticity. Deep dry needling also induced changes in plantar pressure by increasing the support surface and decreasing the mean pressure.
Question by Dr. Vindhya - Sometimes patients with Vit B12, D3 and calcium deficiencies happens to face such ailments or other. For eg. Cervical Spondylitis with headache with or without radiculopathy. They often present with TrP or sharp pain at particular points like attachments of trapezius, at nape of neck or SCM muscle insertion behind ear lobe. Or say some localized pain in small joints due to overuse or stress.
ReplyDeleteWhether DN at such points helps in giving temporary relief?
Is DN done only over points patient complain of pain?
Answer - Yes DN will provide temporary relief if performed correctly by PT. Certain points are dangerous and you have asked about same muscles. Chances of Pneumothorax is more in case of Upper Trapezius. With SCM chances of stimulating baroreceptors are more. And at nape of neck, direct insertion in spinal cord is there. These are areas where precautionary measures should be taken. Also superficial dry needling will be choice of treatment in such cases. In case of chronic pain arising because of deficiencies, a proper differential diagnosis is must. Fibromyalgia is one such neuromusculoskeletal condition where tender points are more common. A detailed evaluation is must to check whether the patient has Fibromyalgia with associated co morbidities. This is imp coz studies shows that DN is not much effective in relieving pain of tender points of Fibromyalgia.
DN is applied mainly on the site of pain. If combination of DN and TENS is there, it would be more effective.
Answer -
"Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation."
DN is used for treatment of excessive muscle tension, scar tissue, fascia, and connective tissues.
DN is also indicated with restrictions in range of motion due to contractured muscle fibers or taut bands, or other soft tissue restrictions, such as fascial adhesions or scar tissue. TrPs have been identified in numerous diagnoses, such as radiculopathies, joint dysfunction, disk pathology, tendonitis, craniomandibular dysfunction, migraines, tension-type headaches, carpal tunnel syndrome, computer-related disorders, whiplash associated disorders, spinal dysfunction, pelvic pain and other urologic syndromes, post-herpetic neuralgia, complex regional pain syndrome, nocturnal cramps, phantom pain, and other relatively uncommon diagnoses such as Barré Liéou syndrome, or neurogenic pruritus, among others.
Question by Dr. Ashiyana - Can it be used to reduce Headaches? For Frontalis muscle?
ReplyDeleteAnswer - Yes for both.
The DN Advanced courses covers head, neck, facial muscles & the muscles of the hand.
Question by Dr. Ashiyana - Can it be used over bones or bony prominences for bone pain?
ReplyDeleteAnswer - Few PTs take Bones as back stops.
In case of Medial and lateral epicondyles— few PTs do needling of the bone and tendon for microtrauma
Dangerous or vulnerable points includes Trapezius. Needling in this region should be away from lung tissue as well as bone or cartilage.
Over the sternum and over the infrascapular fossa should be needled superficially or obliquely due to congenital foramen in these boney structures which are evident in a percentage of population.
Remember DN is "intramuscular stimulation"!
DeleteQuestion by Dr. Deepak - What is the effectiveness ratio of dry needling vs non invasive therapeutic treatment options?
ReplyDeleteAnswer - The treatment options for active MTrPs: transcutaneous electrical nerve stimulation (TENS), electrical muscle stimulation (EMS), ischemic compression, myofascial release therapy, stretch with coolant spray, interferential current, stretch, ultrasound, direct dry needling,
trigger point injection (with various solutions and medications), neuroreflexotherapy, deep pressure soft-tissue massage, hydrocollator superficial heat, exercise, yoga, acupuncture, ice massage, magnetic stimulation, laser therapy, botulinum toxin, topical anesthetic preparation, passive rhythmic release, active rhythmic release, counterstrain, high-velocity low-amplitude thrust, sulfur mud baths, biofeedback, and clinical psychophysiology.
Summary of Evidence for pain relief using different modalities for MPS -
* Laser Therapies - unclear evidence
* Electrotherapies - TENS appears to have an immediate effect, there is limited evidence for the use of FREMS, HVGS, EMS, and IFC for MTrP pain
* Ultrasound - Moderate evidence
* Physical/Manual Therapies - moderate level
Several studies reported that exercise and stretching appeared to be the effective therapy when included in treatment groups comparing active to placebo modalities.
Effectiveness of Trigger Point Dry Needling - The effectiveness of TrP-DN is, to some extent, dependent upon the ability to accurately
palpate MTrPs. Without the required excellent palpation skills, TrP-DN can be a rather random process.
Considering the invasive nature of TrP-DN, it is very difficult to judge the effectiveness. When researchers use minimal, sham, superficial, or placebo needling, there is growing evidence that even light touch of the skin can stimulate mechanoreceptors coupled to slow conducting afferents, which causes activity in the insular region and subsequent increased feelings of well-being and decreased feelings of unpleasantness.
Reference - MYOFASCIAL TRIGGER POINTS Pathophysiology and Evidence - Informed Diagnosis and Management
DeleteEdited by
Jan Dommerholt, PT, DPT, MPS, DAAPM
Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, FAAOMPT, FCAMT
Question by Dr. Nimisha - Recent Evidence for Dry Needling effectiveness!
ReplyDeleteAnswer -
Comparison of dry needling and physiotherapy in treatment of myofascial pain syndrome
Rayegani, Seyed Mansoor; Bayat, Masume; Bahrami, Mohammad HasanView Profile; Raeissadat, Seyed Ahmad; Kargozar, Elham. Clinical Rheumatology33.6 (Jun 2014): 859-64.
Abstract
To compare the effects of dry needling and physiotherapy in treatment of myofascial pain syndrome, a randomized controlled trial was performed on 28 patients with myofascial pain syndrome (MPS) of upper trapezius muscle in the Physical Medicine and Rehabilitation Center of Shohadaye Tajrish Hospital from April 2009 to April 2010. After matching the age, sex, duration of symptoms, pain severity, and quality of life measures, subjects were randomly assigned into two subgroups of case (dry needling) and control (physiotherapy). One week and 1 month after receiving standard therapeutic modalities, outcomes and intragroup and intergroup changes in pain severity, pressure pain of trigger point (TP), and quality of life measures were evaluated and compared. After 1 month, both the physiotherapy and dry needling groups had decreased resting, night, and activity pain levels (p<0.05). Pressure pain threshold of TP and some scores of quality of life (SF-36) were improved (p<0.05). Overall results were similar in both groups. It seems that both physiotherapy modalities and dry needling have equal effect on myofascial pain of the upper trapezius muscle.
J Orthop Sports Phys Ther. 2013 Sep;43(9):620-34. doi: 10.2519/jospt.2013.4668.
DeleteEffectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis.
Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M.
Abstract
STUDY DESIGN:
Systematic review and meta-analysis.
BACKGROUND:
Myofascial pain syndrome (MPS) is associated with hyperalgesic zones in muscle called myofascial trigger points. When palpated, active myofascial trigger points cause local or referred symptoms, including pain. Dry needling involves inserting an acupuncture-like needle into a myofascial trigger point, with the goal of reducing pain and restoring range of motion.
OBJECTIVE:
To explore the evidence regarding the effectiveness of dry needling to reduce pain in patients with MPS of the upper quarter.
METHODS:
An electronic literature search was performed using the key word dry needling. Articles identified with the search were screened for the following inclusion criteria: human subjects, randomized controlled trial (RCT), dry needling intervention group, and MPS involving the upper quarter. The RCTs that met these criteria were assessed and scored for internal validity using the MacDermid Quality Checklist. Four separate meta-analyses were performed: (1) dry needling compared to sham or control immediately after treatment, (2) dry needling compared to sham or control at 4 weeks, (3) dry needling compared to other treatments immediately after treatment, and (4) dry needling compared to other treatments at 4 weeks.
RESULTS:
The initial search yielded 246 articles. Twelve RCTs were ultimately selected. The methodological quality scores ranged from 23 to 40 points, with a mean of 34 points (scale range, 0-48; best possible score, 48). The findings of 3 studies that compared dry needling to sham or placebo treatment provided evidence that dry needling can immediately decrease pain in patients with upper-quarter MPS, with an overall effect favoring dry needling. The findings of 2 studies that compared dry needling to sham or placebo treatment provided evidence that dry needling can decrease pain after 4 weeks in patients with upper-quarter MPS, although a wide confidence interval for the overall effect limits the impact of the effect. Findings of studies that compared dry needling to other treatments were highly heterogeneous, most likely due to variance in the comparison treatments. There was evidence from 2 studies that lidocaine injection may be more effective in reducing pain than dry needling at 4 weeks.
CONCLUSION:
Based on the best current available evidence (grade A), we recommend dry needling, compared to sham or placebo, for decreasing pain immediately after treatment and at 4 weeks in patients with upper-quarter MPS. Due to the small number of high-quality RCTs published to date, additional well-designed studies are needed to support this recommendation.
LEVEL OF EVIDENCE:
Therapy, level 1a-.
Int J Sports Phys Ther. 2014 Oct;9(5):699-711.
DeleteTreatment of nonspecific thoracic spine pain with trigger point dry needling and intramuscular electrical stimulation: a case series.
Rock JM1, Rainey CE1.
Abstract
STUDY DESIGN:
Case Series.
BACKGROUND AND PURPOSE:
Myofascial trigger points (MTrPs) are a common occurrence in many musculoskeletal issues and have been shown to be prevalent in both subjects with nonspecific low back pain and whiplash associated disorder. Trigger point dry needling (DN) has been shown to reduce pain and improve function in areas such as the cervical and lumbar spine, shoulder, hip, and knee, but has not been investigated in the thoracic spine. The purpose of this case series was to document the use of DN with intramuscular electrical stimulation (IES) in subjects with nonspecific thoracic spine pain.
CASE DESCRIPTION:
The subjects were both active duty military males aged 31 and 27 years who self-referred to physical therapy for thoracic spinal pain. Physical examination demonstrated thoracic motor control dysfunction, tissue hypertonicity, and tenderness to palpation of bilateral thoracic paraspinal musculature in both subjects. This indicated the presence of possible MrTPs. Objective findings in the first subject included painful thoracic flexion and bilateral rotation in each of these planes of movement. Pain reduction was observed when postural demands of the spine and trunk musculature were reduced through positional changes. Patient 1 demonstrated pain with posterior to anterior (P/A) pressure at T9 to T12. The second subject had bilaterally limited and painful thoracic rotation actively with normal passive rotation and demonstrated pain with P/A pressure at T4 to T7.
INTERVENTION:
The subjects were treated with DN and IES for a total of two visits each. DN was performed to paraspinal and multifidus musculature at the levels of elicited pain with P/A testing and IES set at a frequency level of 4 (1.5Hz) for 20 minutes.
OUTCOMES:
Subject 1 reported reduced pain with standing flexion from a 62mm VAS score on initial evaluation to 26mm at his second visit. Subject 2 reported being "quite a bit better" in symptoms on the GROC following his second treatment. His VAS score reported following weightlifting activities changed from 43mm on initial evaluation to 20mm at his second visit. Both subjects also demonstrated a 10 degree improvement in active thoracic spinal rotation (on the right for Subject 1 and bilateral for Subject 2) following their second treatment.
DISCUSSION:
Both subjects demonstrated motor control dysfunctions and pain with P/A pressure in the thoracic spine. With the use of DN and IES, immediate reduction was seen in subject perceived symptoms, and pain free ROM was improved. Extended treatment and follow up was not plausible due to the high pace tempo and demands of their operational training schedule. With research indicating the influence of MTrPs on a multitude of musculoskeletal issues and the prevalence of thoracic spine pain, further research is indicated for examining the effects of DN and IES for motor control and painful conditions occurring in the thoracic spine.
LEVEL OF EVIDENCE:
Level 4.
A Novel Treatment Modality for Myofascial Pain Syndrome: Hyperbaric Oxygen Therapy
DeleteKiralp, Mehmet Zeki, MD; Uzun, Günalp, MD; Dinçer, Ümit, MD; Sen, Ahmet, MDView Profile; Yildiz, Senol, MD; et al. Journal of the National Medical Association101.1 (Jan 2009): 77-80.
Abstract (summary)
The aim of the present study was to evaluate the effects of hyperbaric oxygen (HBO) therapy on myofascial pain syndrome (MPS). Thirty patients with the diagnosis of MPS were divided into HBO (n=20) and control groups (n=10). Patients in the HBO group received a total of 10 HBO treatments in 2 weeks. Patients in the control group received placebo treatment in a hyperbaric chamber. Pain threshold and visual analogue scale (VAS) measurements were performed immediately before and after HBO therapy and 3 months thereafter. Additionally, Pain Disability Index (PDI) and Short Form 12 Health Survey (SF-12) evaluations were done before HBO and after 3 months. HBO therapy was well tolerated with no complications. In the HBO group, pain threshold significantly increased and VAS scores significantly decreased immediately after and 3 months after HBO therapy. PDI, Mental and Physical Health SF-12 scores improved significantly with HBO therapy after 3 months compared with pretreatment values. In the control group, pain thresholds, VAS score, and Mental Health SF-12 scores did not change with placebo treatment; however, significant improvement was observed in the Physical Health SF-12 test. We concluded that HBO therapy may be a valuable alternative to other methods in the management of MPS. Our results warrant further randomized, double-blinded and placebo-controlled studies to evaluate the possible role of HBO in the management of MPS.
A Novel Treatment Modality for Myofascial Pain Syndrome: Hyperbaric Oxygen Therapy
DeleteKiralp, Mehmet Zeki, MD; Uzun, Günalp, MD; Dinçer, Ümit, MD; Sen, Ahmet, MDView Profile; Yildiz, Senol, MD; et al. Journal of the National Medical Association101.1 (Jan 2009): 77-80.
Abstract (summary)
The aim of the present study was to evaluate the effects of hyperbaric oxygen (HBO) therapy on myofascial pain syndrome (MPS). Thirty patients with the diagnosis of MPS were divided into HBO (n=20) and control groups (n=10). Patients in the HBO group received a total of 10 HBO treatments in 2 weeks. Patients in the control group received placebo treatment in a hyperbaric chamber. Pain threshold and visual analogue scale (VAS) measurements were performed immediately before and after HBO therapy and 3 months thereafter. Additionally, Pain Disability Index (PDI) and Short Form 12 Health Survey (SF-12) evaluations were done before HBO and after 3 months. HBO therapy was well tolerated with no complications. In the HBO group, pain threshold significantly increased and VAS scores significantly decreased immediately after and 3 months after HBO therapy. PDI, Mental and Physical Health SF-12 scores improved significantly with HBO therapy after 3 months compared with pretreatment values. In the control group, pain thresholds, VAS score, and Mental Health SF-12 scores did not change with placebo treatment; however, significant improvement was observed in the Physical Health SF-12 test. We concluded that HBO therapy may be a valuable alternative to other methods in the management of MPS. Our results warrant further randomized, double-blinded and placebo-controlled studies to evaluate the possible role of HBO in the management of MPS.
Question by Dr. Ruqaya - Is there any problem with incorrect/improper application of DN?
ReplyDeleteAnswer - Apart from precautions and contraindications, adverse reactions should also be known.
1. Painful Treatment
2. Haematoma
3. Fainting
4. Stuck Needle
5. Bent Needle
6. Broken Needle
7. Infection
8. Pneumothorax
9. Needling over spinal cord
10. Needling over abdominal organs
11. Miscarriage
12. Needle Stick Injury
Question by Dr. Farooq - Can we use any electrical modalities before or after the treatment?
ReplyDeleteAnswer - Yes you can use electrical modalities but precautionary measures should be taken if hematoma or bleeding is observed, or in case of any sign of infection or inflammation is seen. Below is one example of a study with DN + Heat Therapy
Evid Based Complement Alternat Med. 2014;2014:638268. doi: 10.1155/2014/638268. Epub 2014 Oct 14.
Effects of Temperature on Chronic Trapezius Myofascial Pain Syndrome during Dry Needling Therapy.
Wang G, Gao Q, Hou J, Li J.
Abstract
The purpose of this study was to investigate the effects of temperature on chronic trapezius myofascial pain syndrome during dry needling therapy. Sixty patients were randomized into two groups of dry needling (DN) alone (group A) and DN combined with heat therapy group (group B). Each patient was treated once and the therapeutic effect was assessed by the visual analogue scale (VAS), pressure pain threshold (PPT), and the 36-item short form health survey (SF-36) at seven days, one month, and three months after treatment. Evaluation based on VAS and PPT showed that the pain of patients in groups A and B was significantly (P < 0.05) relieved at seven days, one month, and three months after treatment Compared to before treatment. There was significantly (P < 0.05) less pain in group B than group A at one and three months after treatment. The SF-36 evaluation demonstrated that the physical condition of patients in both groups showed significant (P < 0.05) improvement at one month and three months after treatment than before treatment. Our study suggests that both DN and DN heating therapy were effective in the treatment of trapezius MPS, and that DN heating therapy had better long-term effects than DN therapy.
There are many PTs who use IFT with Dry Needling & TENS with Dry Needling too.
DeleteQuestion by Dr. Ajay Joshi - Effectiveness of DN for Osteoarthritis.
ReplyDeleteAnswer - Yes effective
Trigger point acupuncture for treatment of knee osteoarthritis - a preliminary RCT for a pragmatic trial
Itoh, Kazunori; Hirota, Satoko; Katsumi, Yasukazu; Ochi, Hideki; Kitakoji, Hiroshi. Acupuncture in Medicine26.1 (2008): 17-26.
Abstract (summary)
There is evidence for the efficacy of acupuncture treatment in knee osteoarthritis, but it remains unclear which acupuncture modes are most effective. We evaluated the effects of trigger point acupuncture on pain and quality of life in knee osteoarthritis patients, compared with acupuncture at standard points, and sham acupuncture.
Thirty patients (27 women, 3 men; aged 61-82 years) with non-radiating knee osteoarthritis pain for at least six months and normal neurological examination were randomised to one of three groups for the study period of 21 weeks. Each group received five acupuncture treatment sessions. The standard acupuncture point group (n=10) received treatment at traditional acupuncture points for knee pain; the trigger point acupuncture group (n=10) received treatment at trigger points; and the third group (n=10) received sham acupuncture treatment at the trigger points. Outcome measures were pain intensity (visual analogue scale, VAS) and WOMAC index (Western Ontario and McMaster Universities Arthritis Index). The groups were compared by the area under the curve method.
Five patients dropped out of the study because of lack of improvement, and one patient (in the trigger point acupuncture group) dropped out because of deterioration of symptoms; the remaining 24 patients were included in the analysis. After treatment, the trigger point acupuncture group reported less pain intensity on VAS than the standard acupuncture or sham treatment group, but both the trigger point acupuncture and standard acupuncture groups reported improvement of function of knee. There was a significant reduction in pain intensity between pre-treatment and five weeks after treatment for the trigger point acupuncture (P<0.01) and standard acupuncture groups (P<0.01) included in the analysis, but not for the sham treatment group. Group comparison using the area under the curves demonstrated a significant difference only between trigger point acupuncture and sham treatment groups analysed (P<0.025 for VAS, and P<0.031 for WOMAC).
These results suggest that trigger point acupuncture therapy may be more effective for osteoarthritis of the knee in some elderly patients than standard acupuncture therapy.
Question by Dr. Vijay Bhardwaj - Can DN be used in Diabetic patients?
ReplyDeleteAnswer - No
Due to loss of sensation and time take to heal.
Even chances of bleeding will be more in Diabetic Patients.
There are no studies done on Diabetic using Dry Needling.
Question by Dr. Ritesh Jain - Is there any comparative study done on IFT Vs Dry Needling with stimulation?
ReplyDeleteAnswer - To my knowledge, there is no such study done so far. Lack of evidence is clear in case of MPS and its choice of treatment modalities.
if anyone is looking for more Physiotherapi services
ReplyDelete1 in 3 Women who had a baby wet themselves
Incontinence could be urinary incontinence and faecal incontinence. Incontinence is the inability to control micturition resulting in the loss of urine. These dysfunctions are caused by pregnancy & childbirth,poor pelvic floor muscle function,constipation,poor fluid & toileting habits,chronic cough,obesity, strenuous sports, aging & menopause ,neurological conditions like MS and stroke Bladder Disorders / Bladder Dysfunction
Womens Health Clinic in Melbourne