REVITALIZE 2018...4/10/18 1 Dry Needling Paul Thomas, PT, DPT, OCS, FAAOMPT 2018 CONFERENCE & EXPO Material presented at IPTA 2018 REVITALIZE Conference “Myofascial pain is arguably

4/10/18

DryNeedlingPaulThomas,PT,DPT,OCS,

FAAOMPT

2018CONFERENCE&EXPO

MaterialpresentedatIPTA2018REVITALIZEConference

“Myofascialpainisarguablythemostcommoncauseofpaintoafflicthumankind”

-Gerwin,2011

•  JanetTravelrediscoveredtriggerpointsintheearly1940’sanddevelopedtheideaoftriggerpointinjecZons

•  By1944theideathattheneedlemaybepartlyresponsibleforthetherapeuZceffectshadalreadybeenmenZoned

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•  Atfirstmanagementofmyofascialpainwithinvasivetechniqueswasreservedforphysicians

•  MostMD’spreferredinjecZonsoverdryneedling

Theneedleeffect

•  In1979,KarlLewitpublishedontheneedleeffect§  Achievedsuccessfuloutcomesin86%ofpaZentstreated§  Successdefinedasimmediateanesthesia

Acupuncturists

•  Inthe1980’ssomeacupuncturistsawareofTravellandSimons’workanddevelopedaninterestinthetriggerpointconcepts§  Seem2007

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PhysicalTherapists

•  PT’sthathadstudiedwithDr.JanetTravelldevelopedaninterestindryneedling

•  1984MarylandBoardofPhysicalTherapyExaminerswasthefirstintheUStoapproveddryneedlingaswithinthescopeofPTpracZce

MyofascialTriggerpoint

•  TrP’scanbepresentasaprimaryproblemandindependentcauseofpain

•  Ortheycanbeaco-morbiditysecondarytoamedicalissue§  OAorotherjointproblems(e.g.,knee,hip,etc)§  Systemicdiseases§  NutriZonaldisorders(e.g.,vitamindeficiencies)§  VisceraldysfuncZons(e.g.,endometriosis,intersZtalcysZZs,IBS,prostaZZs)

•  TriggerpointscanpersistbeyondtheduraZonoftheiniZaZngcondiZon

•  MusclehavevarietyofnocioceptorsthatcanbeacZvatedbymechanicalorchemical

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TrPDefined

•  Atriggerpointisahyperirritablespotinatautbandofaskeletalmusclethatispainfuloncompression,stretch,overload,orcontracZonoftheZssuewhichusuallyrespondswithareferredpainthatisperceiveddistantfromthespot§  Simonsetal.1999

AcZveorLatent

•  LocalandreferredpainfromacZvetriggerpointsreproducessymptomsreportedbypaZents

•  BothacZveandlatenttriggerpointscauseallodyniaattheTrPandhyperalgesiaawayfromtheTrP

•  LatenttriggerpointsthelocalandreferredpainarenotrecognizedasbeingusualpainthatpaZentexperiences

Latenttriggerpoints

•  AlthoughlatenttriggerpointsarenotproducingacZvepain,theyprovidenociocepZveinputtothedorsalhorn(Geetal.2008,2009,Ge&Arendt-Nielson2011)

•  LatentTrPcanbecomeacZvetriggerpointswithcentralsensiZzaZonandincreasedefficacyinthedorsalhorn

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AcZveTrP’s

•  AcZvetriggerpointsinducelargerreferredpainareasandhigherpainintensiZes(Hongetal2000)

•  OverlyingcutaneousandsubcutaneousZssuesmoresensiZvetopressureandelectricalsZmulaZonthanlatentTrP’s.(Vecchietetal.1990)

•  BothacZveandlatenttriggerpointscanprovokemuscledysfuncZons§  Muscleweakness§  InhibiZon§  Increasedmotorirritability§  Spasm§  Muscleimbalance§  Alteredmotorrecruitment

•  ChangesoccurintheeffectedmuscleorfuncZonallyrelatedmuscles

MotoracZvaZonlatentTrP

•  Lucasetal2010demonstratedimpairedmotoracZvaZonpamernsinlatenttriggerpoints

•  CorrecZonoftheTrPnormalizedthemotoracZvaZon

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Referredpain

•  Mensedescribedreferredpaincomingfromdeepstructures(muscles,joint,tendons,viscera)asdeep,diffuse,anddifficulttolocalize

•  Referredpaincanbeexperiencedanywhereinthebody

•  Sizeofthereferredareaisvariableandrelatedtothepaininducedchangesinthecentralsomatosensorymaps

Referredpain

•  Characterizedby:§  DuraZonofreferredpaincanlastafewsecondstohours,weeks,or

indefinitely.§  Deep,diffuse,burning,Zghtening,orpressingpain(completely

differentfromneuropathicorcutaneouspain)§  SimilarreferralofpainfrommuscleZssuesasreferralfromjoints§  Referredpaincanspreadsuperior/inferiororventral/dorsal§  IntensityofpainandsizeofreferredareaareposiZvelycorrelatedto

thedegreeofirritabilityofthecentralnervoussystem(sensiZzaZon)§  FrequentlyfollowsdistribuZonofscleratomes,notdermatomes§  Maybeaccompaniedbynumbness,coldness,sZffness,weakness,

faZgue,ormotordysfuncZon

§  Arendt-Nielsen&Ge2009,Fernandez-de-las-Penasetal2011

BasisofReferredPain

•  Convergent-projecZontheory(1961)§  AfferentsfromdifferentZssuesincludingskin,viscera,muscles,andjointsconvergeontocommonspinalneuronswhichleadstomisinterpretaZonofthesourceofthenociocepZveacZvityfromthespinalcord

§  Doesn’texplainthedelayinonsetofsymptoms

•  Covergence-facilitaZontheory§  SomatosensorychangesinthereferredareaduetosensaZzaZonmechanismsinthedorsalhornandbrainstemneurons

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BasisofReferredPain

•  Thalamic-convergencetheory(1949)§  SummaZonofinputfrominjuredareaandfromreferredareawithin

neuronsinthebrain,butnotinthespinalcord§  EvidenceofpainreducZonwithanestheZzingthereferredarea

suggesZngaperipheralprocesscontributes§  Centralprocessarebelievedtobedominant

•  Central-Hyper-excitabilitytheory§  FollowingnoxioussZmulus,dorsalhornneuronsthatwerepreviously

responsivetoonlyoneareawithinamusclebegantorespondtonociocepZonfromareasthatdidnotpreviouslytriggeraresponse

§  LatentconvergentafferentsonthedorsalhornneuronareopenedbynoxioussZmulifrommuscleZssues

NatureofTrPs

•  Tautbandscanbepalpatedwithflatorpincergrip•  TautbandsignifiescontracZonwithinacertainnumber

ofmusclefibersindependentofelectromyogenicacZvityanddoesnotinvolvetheenZremuscle

•  Localtwitchresponseusuallyoccurswithmanualstrummingorneedling

•  Canbeobservedvisually,recordedonEMG,orvisualizedwithdiagnosZcUS

•  NumberofLTR’smayberelatedtotheirritabilityofthemusclewithmayberelatedtothedegreeofsensiZzaZonofnocioceptors(Biochemicalchanges)

LTR’s

•  EliciZngtheLTRhasbeenadvocatedforneedling(Hong1994,Shah2005)

•  Shah2005observedimmediatedropinconcentraZonsofbiochemicalsintheextracellularfluidoflocalTrP’s

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TrPDevelopment

•  MayresultfromrepiZZvemuscleoveruse,acuteorsustainedoverload,psychologicalstress,orotherprimaryTrP

•  FollowingintenseconcentriccontracZonoreccentriccontracZons

•  Muscletrauma,repeZZvelowintensitymuscleoverloadmaycreatedamageinthesacroplasmicreZculumorcellmembrane,shortageofATP,andimpairedcalciumconcentraZon,shorteningofacZn/myosin

MTrPDevelopment

•  MTrPmaydevelopintheabsenceofmedicalproblemsorasaco-morbiditywithothercondiZons

•  MTrPcanbeassociatedwithsystemicdiseases,arthriZccondiZons;metabolic,parasiZc,ornutriZonaldisorders;secondarytoinjuries

•  PainfromMTrPcancauseseparateandindependentcauseofacuteandespeciallychronicpainthatmaycompoundthesymptomsoftheothercondiZonandmaypersistaqertheoriginaliniZalizingcondiZonhasresolved

Integratedmodel

•  ProposesthatabnormaldepolorizaZonofpost-juncZonalmembraneofmotorendplatescauseslocalhypoxiaacZvaZngreflexarcsthensustainedbysensaZzaZonmechanisms

•  Musclespindlesalsoinvolved.H-reflexesassociatedhavegreateramplitudesandlowerthresholds

•  Believedtoberelatedtogreaterexcitabilityofmusclespindleafferents(Geetal2009)

•  IncreasedchemicalmediatorsmaycontributetoincreasedspindlesensiZvity(Shahetal2005)

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ProposedmechanismsforTDN

•  MechanicallyitmaydisruptcontracZonknots,stretchcontracturedsacromeres,reduceoverlapofacZn/myosin

•  MaydestroymotorendplatesandcausedistalaxondenervaZonandchangesintheendplatecholinesteraseandacetylcholinereceptorsimilartonormalmuscleregeneraZonprocess

•  ReducedendplatenoisefollowingLTRfromTDN

AcetylcholineresponsetoTDN

•  DecreasedSpontaneousElectricalAcZvityandAcetylocholineatMyofascialTriggerSpotsaqerDryNeedlingTreatment§  Ratstudy,dividedinto2groupsreceivingTDNtotriggerpointornon-triggerpoints

§  Dryneedlingtreatmentlast2weeks,onceperweek§  SEAs,Ach,AChR,AChElevelsmeasuredaqeroneweekresyofdryneedling

§  ResultsAmplitudeandfrequenciesofendplatenoiseandendplatespikessignificantlydecreasedaqerTDNingroupreceivingtreatmenttoMTrP

§  AchandAChRlevelssignificantlydecreasedandAChEsignificantlyincreasedintreamentgroup

Mechanisms

•  LTRreducesconcentraZonsofbiochemicalsintheimmediateareaofTrP’sincludingCGRP,substanceP,serotonin,interleukins,epinepherine

•  DropinsubstancePandCGRPlikelycorrespondwiththedecreasedpainfollowingTDN

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Mechanisms

•  Effectonthecentralnervoussystem§  hasbeensuggestedthatneedlinghaseffectsonlimbicsystemanddescendinginhibitorysystem

•  StudiesonTDNoffibromyalgiapaZentsdemonstratesthatneedlingafewpointsonpaZentsreducespainnotonlyinthetreatedareasbutreducesoverallsensiZvityandwidespreadpain.

Mechanisms

•  ReducessegmentalnociocepZveinput

•  ExperimentallyinducedmusclepainimpairsnoxiousinhibitorycontrolmechanismsandTDNseemstoeffectcentralsensiZzaZonbyalteringthenociocepZveprocessing

ConnecZveZssueresponse

•  Langevinetal.mulZplestudies•  Whenneedlesrotatedcollagenbundleadheretotheneedleand

winditselfaroundtheshaqinimmediatevicinity•  StretchismaintainedaqertherotaZngtheneedleifleqinplace•  Sustainedstretchcausesvisco-elasZcrelaxaZon,Zssuetension

dropsandsemlesatequilibriumduetomolecularreorganizaZonwithinthecollagenmatrix

•  ConnecZveZssuefibroblastsrespondbychangingshape,formaZonofnewcytoplasmicextensions.

•  Remodelingofcell’scytoskeleton•  ChangecausesfurtherreducZoninZssuetensionthenthat

achievedbyviscoelasZcrelaxaZon•  Fibroblastsresponduptoseveralcmawayfromtheneedle•  Needlesrequiredtostayinforlongperiod(10’)

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SuperficialTDNMechanisms

•  AmributedtothesZmulaZonofA𝛿fiberswhichmayoutlastthesZmulusforupto72hours(Baldry2005)

•  TypeIhighthresholdfibersacZvatedbynociocepZvemechanicalsZmulaZon

•  SZmulaZonofA𝛿fibersmayacZvateenkephalinergic,seratonergic,andnoradrenergicinhibitorysystems

•  MayacZvatemechanoreceptorscoupledtoslowconducZngunmyelinatedCfiberafferents

SuperficialDryNeedling

•  PeterBaldrybeganemployingthetechniqueinthe1980’s§  .3mmneedle,30mmlength§  Insertfor30secondsabovetheMTrPtobeinacZvated§  Iffailstorespondthenwillleaveforupto2-3minutes§  IfveryweakresponderthenmayintermimentlytwirltheneedletosZmulate

Gunn-IMS

•  GunnIntramuscularSZmulaZon•  Developedinthe1970’sbyChanGunn,MD•  Cannon’s“SupersensiZvityofDenervatedStructures,aLawofDenervaZon”

•  Believedinradiculo-neuropathic-myofascialpain(RNMP)

•  Leadtolookingforsegmentalmyotomalinvolvement

•  PredictstriggerpointsinmyotomaldistribuZonincludingtheposteriorramus

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•  Increasedmuscletone•  Neurogenicedema–matchsZcktest,peaud’orange•  Vasomotordisturbanceswithhypothermia–coolertopalpaZon

•  Exaggeratedpilomotorandsudomotorreflexes–goosebumps,increasedsweat

•  Dermatomalhairloss

CannonandRosenbluth’sLaw

•  Whenaunitisdestroyedinaseriesofefferentneurons,anincreasedirritabilitytochemicalagentsdevelopsintheisolatedstructureorstructures,theeffectbeingmaximalinthepartdirectlydenervated

BiomedicalAcupuncture

•  WMAisatherapeuZcmodalityinvolvingtheinserZonoffineneedles;itisanadaptaZonofChineseacupunctureusingcurrentknowledgeofanatomy,physiologyandpathology,andtheprinciplesofevidencebasedmedicine

•  Characterizedbydryneedlingoftriggerpointsandsegmentalacupuncture(needlingofanareainnnervatedbythesamespinalsegment

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Biomedicalacupuncture

•  Localeffects•  Segmentalanalgesia

§  SZmulatestheA𝛿fibersinskinandmuscle§  TheseacZvatesmallintermediatecellsinthedorsalhorn§  IntermediatecellsreleaseneuromodulatorenkephalinwhichblocksthetransmissionofpaininthesubstanZagletainosacells,partofthenociocepZvepathway(fromtheunmyelinatedC-fibers

•  Extrasegmentalanalgesia

BiomedicalAcupuncture

•  ExtrasegmentalAnalgesia§  OpioidpepZdes(neuromodulators):

•  β-endorphin(midbrain,PAG)•  Enkaphalin(dorsalhornofspinalcord)•  Dynorphin(brainandspinalcord)•  Orphanin–akaendomorphinornocicepZn(widespread)

§  HaveeffectontargetcellforsustainedperiodofZme•  Descendinginhibitorypaincontrol

§  PAGacZvatedbyβ-endorphin,releasedfromfibersdescendingfromthehypothalamusspecificallythearcuatenucleuswheresomeafferentpathwaysoftheA𝛿terminate

Extrasegmentaleffects

•  Descendingpaincontrolreleasesserotonin,sZmulaZngtheintermediatecelltoreleasemet-enkephalinwhichinhibitsthesubstanZagelaZnosacells(addiZonaltothesegmentalinhibiZonalreadyacZvated)

•  Alsocausesreleaseornoradrenalinediffuselythroughoutthedorsalhornwhichhasadirectinhibitoryeffectonpost-synapZcmembraneoftransmissioncellsfurthercontrollingnociocepZon

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•  2Hz–releasesβ-endorphin,enkephalin,andorphanin

•  80-100Hz–releasesdynorphin•  15Hz–limitedreleaseofenkephalinandβ-endorphin

AdverseEventsreportedin7629treatmentswithTDN

Event CasesReported Numberper100treatments

Number(%)ofPT’srepor<ngnone

Extremevaluesbyindividualprac<onersper100treatments

Bleeding 576 7.55 4(10.25) 32.23,30

Bruising 355 4.65 3(7.69) 26.09,21.84

Painduringtreatment

230 3.01 9(23.08) 20.75,20.69

Painaqertreatment

167 2.19 14(35.9) 20.69,18.4

AggravaZon 67 0.88 22(56.41) 10.99,5.75

Drowsiness 20 0.26 32(82.05) 4.44,3.26

Feelingfaint 17 0.22 28(71.79) 4.17,2.5

Headache 11 0.14 31(79.49) 1.15,1.1

Nausea 10 0.13 31(79.49) 1.15,1.1

FaZgue 3 0.04 37(94.87) 1.77,0.27

EmoZonal 3 0.04 37(94.87) 1.59,0.27

Shaky 1 0.01 38(97.44) 3.03

Itching 1 0.01 38(97.44) 0.47

Claustophobia 1 0.01 38(97.44) 0.16

Numbness 1 0.01 38(97.44) 0.47

AdverseEvents

VeryCommon Common Uncommon Rare VeryRare

>10%/>1-10 >1-10%/1-10/100

>0.1%-1%1-10/1000

>0.01%-0.1%1-10/10,000

<0.01%<1/10,000

BleedingHematomaNeedlesitepain

InflammaZonSwellingStrongpainduringNerveirritaZonNerveinjuryHeadacheFaZgueVerZgoNausea

LocalinfecZonRednessItchingSweaZngBloodpressurechangesUnconsciousnessTachycardiaBreathingdifficulZesVomiZng

PneumothoraxBrokenneedleForgomenneedleSystemicinfecZonAffectedspeechDisorientaZon

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Guidelines

•  Handhygiene§  washhandswithsoap/waterorusehandsaniZzersifnotvisiblysoiled

•  Gloves§  UseisinlinewithOSHAguidelines,likelycontactwithblood

•  Skinprep§  NotusuallyrequiredforTDNperWorldHealthOrganizaZonforintradermal,subcutaneous,orintramuscularinjecZons

§  Ifskinisvisiblysoiledshouldbecleanedwithsoap/waterfirst§  Mayuse70%alcoholleqonskinforatleast2minutesespeciallyifpaZentisimmunocompromisedyetsuitableforTDN

AbsoluteContra-indicaZons

•  PaZenthasneedlephobia•  PaZentisunwilling–fear,belief•  Unabletogiveconsent•  AcutemedicalcondiZon•  OveranareaorlimbwithlymphodemaasitmayincreaseriskofcelluliZs/infecZon

•  Inappropriateforanyotherreason

RelaZvecontra-indicaZons

•  Abnormalbleeding•  Compromisedimmunesystem•  Vasculardisease•  Diabetes•  Pregnancy•  Children•  FrailpaZents•  PaZentwithepilepsy•  Psychologicalstatus•  PaZentallergies•  PaZentmedicaZon•  UnsuitablepaZentforanyotherreason

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AnatomicalconsideraZons

•  Lungsandpleura•  Bloodvessels•  Nerves•  Organs•  Joints•  ProstheZcimplants/fixaZondevises•  Implanteddevices

MuscleCramps

•  Geetal2008demonstratedlatenttriggerpointscouldbeatleastparZallyinvolvedinmusclecrampsbyinducingcrampswithglutamateinjecZonsin92.86%ofsubjectstested

•  NocrampswereobservedwheninjecZonoccurredinnon-TrP’s

•  IncreasednociocepZvesensiZvityattheTrPisbelievedtobeonemechanismforthedevelopmentofmusclecramps

EffectsofTDNonPower/ForceProducZon

•  40malesseparatedin4groups§  RectusfemorisTDN§  MedialgastrocTDN§  RectusfemorisandmedialgastrocTDN§  Control(noneedles)

•  Peformedjumpsquatsatincrementalloadsandmeasuredforjumpheight,poweroutput,opZmalforce,andopZmalvelocity

•  Results:§  Immediateincreaseinjumpheightforgroup2(gastroconly)andat48

hourspostintervenZon§  From48hoursonwardatrendwasobservedforjumpheight,power,and

velocity§  AuthorsconclusionthatTDNcausesiniZaldecreasedperformancewith

levelsimprovingabovebaselineaqer48hours

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•  TheassociaZonbetweendryneedling-inducedtwitchresponseandchangeinpainandmusclefuncZoninpaZentswithlowbackpain:aquasi-experimentalstudy.

•  66paZentwithmechanicalLBP•  TDNtoL3andL5bilaterally•  NumericpainraZng,modifiedOswestry,pressurealgometry,ultrasound

imagingbeforeandaqertreatment•  Results:parZcipantswithLTRexhibitedgreaterimprovementinmulZfidus

funcZon12.6%changevs5.7%)•  Howeverdifferencewasnotpresentatoneweek•  Nobetweengroupdifferencesindisability,painintensity,ornociocepZve

sensiZvity.•  ConclusionsthatLTRmaynotbenecessaryforsuccessfultreatment•  ResultsmayhavelastedlongeriffollowedbystrengtheningoracZvaZon

exercises

CosteffecZveness

•  CosteffecZvenessoftheinclusionofTDNintoanExerciseProgramforSubacromialPainSyndrome:EvidencefromaRCT§  50paZentsrandomizedintoexerciseorexerciseplusTDN§  BothgroupsaskedtoperformRCexercises2x/dayfor5weeks§  AllparZcipantssawPTforsupervisedexercisesonceperweekfor5weeks§  PaZentsintheneedlinggroupalsoreceivedTDNon2ndand4thsessions§  SocietalcostsandhealthrelatedQOLovera1yearfollowupwereusedto

generatecostperquality-adjustedlife-year(QALY)raZosforeachintervenZon

§  Exercisegroupmademoredoctorvisitsandreceivedgreaternumberofothertreatments

§  Majorcontributertothesocietalcostswasabsenteeism(lostproducZvity)

TrA/MulZfidus

•  ImmediateChangesinResZngandContractedThicknessofTransversusAbdominisAqerDryNeedlingofLumbarMulZfidusinHealthyParZcipants:ARandomizedControlledCrossoverTrial§  47healthyindividualswithoutLBPinprevious6monthsassignedTDNtomulZfidusorsham-TDN(usedtubeonly).

§  ParZcipantsreceivedbothintervenZonsatleast7daysapart.§  InstructedhowtocontractTrAandmeasuredwithultrasoundatrestandcontractedbeforeandimmediatelyaqereachintervenZonbyevaluatorblindedtotheintervenZonreceived

§  ResultsdemonstratedTDNtothemulZfidus(L4)wasaccompaniedbydecreasedresZngthicknessandincreasedcontracZonthicknessoftheTrA

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MulZfiduschangeswithTDN

•  66volunteerswithmechanicalLBP•  Ultrasoundmeasurementsandpainalgometry(PPT)ofthe

mulZfidustakenatbaseline,immediatelyaqerTDN,and1week.

•  PercentagechangeinmusclethicknessfromresttocontracZonwascalculatedtodeterminemusclefuncZon.

•  ParZcipantdeterminedtoberespondersornon-respondersbasedonimprovementmeasuredwithmodifiedOswestryatoneweek.

•  RespondersexhibitedlargerimprovementsinmulyiduscontracZonandnociocepZvesensiZvityat1week,butnotimmediatelyaqerintervenZonthannon-responders

TDNforLBP

•  Evidencefordryneedlinginthemanagementofmyofascialtriggerpointsassociatedwithlowbackpain:asystemaZcreviewandmeta-analysis§  11RCTinvolving802paZentsincludedinmeta-analysiswithresultssuggesZngthatcomparedtoothertreatements,dryneedlingofMTrPswasmoreeffecZveinallevaiZngintesityofLBPandfuncZonaldisability

§  However,significanteffectsofdryneedlingplusotherintervenZonscouldbesuperiortodryneedlingalonepostintervenZon

§  ConclusionthatTDNofMTrPcanberecommendedespeciallyifassociatedwithotherintervenZonstorelieveintensityofLBP

Heelpain

•  EffecZvenessoftriggerpointdryneedlingforplantarheelpain:ameta-analysisofsevenrandomizedcontrolledtrials

•  Extensiveliteraturereviewfoundonly7RCT’smeeZnginclusioncriteria.

•  PooledresultsshowedMTrPneedlingsignificantlyreducedVASscorecomparedwithcontrol

•  TDNhadsimilaradverseeventincidenceascontrols•  ConclusionTDNeffecZveforreducingheelpainduetoplantarfasciZs

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CervicalPain

•  Beneficialeffectsofdryneedlingfortreatmentofchronicmyofascialpainpersistfor6weeksaqertreatmentcompleZon§  45paZentswith>3monthscervicalpainandMTrP’scompleted3sessionTDNand

evaluated6weeksaqerwards§  VAS,BriefPainInventory(BPI),andMTrPstatus§  RespondersdefinedasthosewhereMTrPchangedfromacZvetolatentornon-palpable

nodule§  SecondaryoutcomesPPT,ProfileofMoodStates,OswestryDisabilityIndex(ODI),MOS

36ItemShortFormHealthSurvey,andcervicalROM§  Results:Painmeasuresremainedsignificantlyimproved6weeksposttreatment,asdid

theSF-36physicalfuncZoningscoreandODI.SidebendingandPPTforsubjectswithunilateralMTrPhadsustainedimprovement.

§  Respondersandnon-responders,changesinVASandBPIwerestaZsZcallysignificant,butchangeinPPTwasnot

§  HigherbaselineVASwasassociatedwithhigherlikelihoodofnotrespondingtoTDN§  GreaterdropofVASfrombaselinewasassociatedwithhigherlikelihoodofsustained

improvement

KneePain

•  EffecZvenessofinclusionofdryneedlinginamulZmodaltherapyprogramforpatellofemoralpain:arandomizedparallel-grouptrial§  60paZentsrandomizedintomanualtherapyandexerciseormanualtherapy,exercise,plusdry

needling§  Bothgroupreceivedthesamemanualtherapyandstrengtheningprogramfor3sessions(1x/wkfor

3wks)§  TDNgroupalsoreceivedTDNtovastusmedialisandlateralis§  PaZentsassessedatbaseline,15dayposttreatmentand3months§  Nosignificantdifferencesbetweengroupsforanyoutcomemeasure(KneeInjuryandOsteoparthriZs

Outcomescale,InternaZonalKneeDocumentaZonCommimeeSubjecZveKneeEvaluaZonForm,painraZng

§  Bothgroupsimprovedoutcomescores§  Conclusion:AddiZonofTDNdidnotresultinanyaddiZonalimprovedoutcomesforpainordisability

TDNvsOMT

•  ComparisonofdryneedlingversusorthopedicmanualtherapyinpaZentswithmyofascialchronicneckpain:asingle-blind,randomizedpilotstudy§  36paZentsplacedintooneof3groups:manualtherapy,TDNandstretching,orsoqZssuetechniques

§  Allgroupsreceived2sessionwith48hoursbetween§  AssessedforNDI,paincatastrophizingscale,VAS,cervicalROM,PPTformechanicalhyperalgesia

§  Results:all3groupsreporteddecreasedpainintensity§  TDNandOMTgroupshadreduceddisability§  TDNandOMTgrouphadincreasedcervicalROM§  ReducedmechanicalhyperalgesiaandpaincatastrophizinginOMTgrouponly

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TDNforshoulderpain

•  Exercisesanddryneedlingforsubacromialpainsyndrome:arandomizedparallel-grouptrial§  50subjectswithsubacromialpainrandomizedtoexercisegroupor

exerciseplusTDN§  ParZcipantsaskedtoperformexercises2x/dayfor5weeks§  Supervisedexerciseonceperweekfor5weeks§  TDNgroupalsoreceivedneedlingtoMTrPsessions2and4§  Assessedatbaseline,1week,3wk,6wk,and12monthsaqer

treatment§  Results:largerimprovementsfortheexerciseplusTDNgroupin

shoulderdisabilityatallf/uperiods§  Bothgroupshadsimilarimprovementsinshoulderpainoutcomesat

allpoints§  Conclusion:TDNeffecZveforimprovingdisabilityinsubacromialpain

syndrome

Flexibility

•  ClinicaleffectsofdryneedlingamongasymptomaZcindividualswithhamstringZghtness:arandomizedcontrolledtrial§  27subjectswithhamstringextensibilitydeficitsrandomizedintoside

oftreatment(non-dominant/dominant)andgroup(bluntneedling/dryneedling)

§  FirstsessionmeasuredHSextensibilityandperformanceon4unilateralhoptests,HEPinstrucZoninHSstretching,andneedlingdistaltoischealtuberosityandmidbelliesofmedial/lateralHS

§  2ndsession3-5daysaqerre-measuredandneedling§  3rdsession4-6weeksforoutcomesonly§  Results:HSextensibilityimprovedinbothgroups,triplehopshowed

improvementforTDN§  Conclusion:Dryneedlingdoesnotresultinincreasedextensibility

beyondthatofstretchingaloneinasymptomaZcgroups

TDNforsportsimprovement

•  Comparisonofdryneedlingvs.shamontheperformanceofverZcaljump§  35parZcipantsdividedintoshamorTDNgroup§  TDNgroupreceivedneedlingto4sitsin(B)gastrocnemiusmuscles,2eachformedial/lateralhead

§  TwoleggedverZcaljumpheightwasrecordedpre-andpost-forbothgroups

§  Results:TDNgroupincreaseverZcalsignificantly(1.2”)overshamgroup

§  Conclusion:singlesessionofTDNcancauseimmediateeffectonincreasingverZcaljumpheight

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TDNforTMD

•  Short-termeffectsofdryneedlingforacZvemyofascialtriggerpointsinthemassetermuscleinpaZentswithtemporomandibulardisorders§  12femaleseachamendedtwosessionsandreceiveddryneedlingorsham,randomizedontwoseparatedays

§  PPTovermasseterandmandibularcondyle,pain-freeacZvejawopeningwereassessedpre-and5minutespostintervenZonbyblindedexaminer

§  Results:subjectsshowedgreaterimprovementinallmeasureswithTDNcomparedtosham

TDNvssteroidforplantarfasciZs

•  ComparisonofdryneedlingandsteroidinjecZoninthetreatementofplantarfasciZs:asingle-blindrandomizedclinicaltrial§  66paZentswithrandomizedtoreceiveddryneedlingor1mlDepo-Medrol

§  F/ufor12monthsandmonitoredforVASatbaseline,3wk,6wk,3month,6months,1year

§  Results:steroidinjecZongroupsignificantlyreducedVASscoresunZl3weeksposttreatmentcomparedtoTDN

§  PaZentsintheTDNgroupreportedlowerVASatendofstudycomparedtosteroidintervenZon

§  Conclusion:steroidcandecreaseheelpainrapidlybutdryneedlingcanprovidemoresaZsfactoryresultsforpaZentswithplantarfasciZslongterm

Deepvssuperficialdryneedling

•  ComparisonofacuteeffectsofsuperficialanddeepdryneedlingintotriggerpointsofthesuboccipitalanduppertrapeziusmusclesinpaZentswithcervicogenicheadache§  30parZcipantswithdiagnosisofcervicogenicHAdividedrandomlyintodeepandsuperficialgroups

§  HeadacheIndex,triggerpointtenderness,cervicalROM,funcZonalraZngindexassessedatbaseline,immediate,and1weekaqertreatment

§  Results:bothgroupsshowedreduucZoninheadacheindexandtriggerpointtenderness.

§  DeepdryneedlinggroupshowedgreaterimprovementincervicalROMandfuncZonalraZngindex

4/10/18

LateralepicondyliZs

•  DryneedlinginlateralepicondyliZs:aprospecZvecontrolledstudy§  PaZentsselectediftheyhadpainatlateralepicondylefor>3months,painduringresistedsupinaZon,andresisted3rdfingerextension

§  PaZentevaluatedwiththePaZent-ratedTennisElbowEvaluaZon(PRTEE)atbaseline,3weeks,and6months

§  110paZentsrandomizedtoreceivedryneedlingoribuprofen100mg2x/dayandforearmbrace

§  TDNtoMTrParoundthelateralepicondyle2x/wkfor5sessions§  Results:bothgroupsimprovedat3weeks,butdryneedlingsignificantlymoreeffecZveat6months

Wryneck

•  ImmediateeffectsofparaspinaldryneedlinginpaZentswithacutefacetjointlockinducedwryneck§  21paZentswithacutefacet

lockedwryneckweretreatedwithsinglesessionofdryneedlingfor12-15minutes.

§  VASandcervicalROMimmediate,24hours,and1week

§  Results:reducedVASandcervicalROMincreasedimmediatelypostintervenZonandwasmaintainedatthe1weekfollowup.

Measure

Baseline

Immediate

24hour 1week

VAS 73.47 18.80 5.85 2.12

Flex/ext 30.38° 95.33°

115.04°

SB 13.76°

91.90°

117.42°

Rot 15.42°

88.28°

107.66°

DiscogenicLBP

•  TheeffectofdryneedlingontheradiaZngpaininsubjectswithdiscogeniclowbackpain:arandomizedcontroltrial§  58paZentswithdiscogenicradicularLBPrandomizedtocontrolgroupand

experimentalgroup§  VAS,OswestryDisabilityIndexatbaseline,endoftreatment,2months

postintervenZon§  ReceivedthermalmodaliZes,US,TENS,exercise(McKenzieand

stabilizaZon).§  Experimentalgroupreceived5sessionsTDNparaspinals,mulZfidus,QL,

glutemax/med/min,piriformis,psoas,HS,gastrocneedledaccordingtopresenceofMTrP’s.

§  SignificantimprovementinVASandOswestryforbothgroupsfollowingintervenZonatduringf/uperiod

§  PainanddisabilityimprovementgreaterintheexperimentalgrouppostintervenZonVAS25.17,ODI22.17vsVAS42.41,ODI30.27)andmaintainedduringf/u

§  ConclusionthatdryneedlingmayenhanceeffectofstandardintervenZon

4/10/18

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REVITALIZE 2018...4/10/18 1 Dry Needling Paul Thomas, PT, DPT, OCS, FAAOMPT 2018 CONFERENCE & EXPO Material presented at IPTA 2018 REVITALIZE Conference “Myofascial pain is arguably

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