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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DryNeedlingPaulThomas,PT,DPT,OCS,

FAAOMPT

2018CONFERENCE&EXPO

MaterialpresentedatIPTA2018REVITALIZEConference

“Myofascialpainisarguablythemostcommoncauseofpaintoafflicthumankind”

-Gerwin,2011

Title


•  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)


MTrP

•  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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Gunn

•  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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E-sZm

•  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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LTR

•  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


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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°

122°

SB 13.76°

91.90°

117.42°

125°

Rot 15.42°

88.28°

107.66°

115°


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


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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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